1. *Neda’a Al-Shamayleh* *Sereen Al-Dalabeeh* *Aroub Al-Zoubi*

2. * Pathophysiology : -The most common virus associated with HIV is the HIV type 1 human retrovirus. - The virus attaches to the surface of CD4+ T lymphocytes (targets of HIV-1). -Billions of viral particles are produced each day by activated CD4 cells.

3. * Transmission : - Transmission is usually SEXUAL or PARENTERAL, other than semen & blood, fluids that transmit the disease are breast milk & vaginal fluid. - Risk of Transmission: -Needle stick injury. -Vaginal (male to female/female to male). -Anal receptive. -Mother to child. -Caesarian delivery is indicated if Viral load is over 1.000 copies.

4. -Mortality is usually secondary to opportunistic infection,cancer. High-risk individuals: - Homosexual or bisexual men. - IV drug abusers. - Blood transfusion recipients. - Heterosexual contacts of HIV-positive individuals. - Unborn & newborn babies of mothers (who are HIV-positive).

6. ** Primary Infection ** - A mononucleosis-like syndrome (about 2-4 weeks after exposure to HIV). -Symptoms: - Fever. - Sweats. - Malaise. - Lethargy. - Headaches. - Arthralgias / Myalgias. - Diarrhea. - Sore throat. - Lymphadenopathy. - Tuncal maculopapular rash.

8. ** Asymptomatic Infection ** - Seropositive, but NO clinical evidince of HIV infection!! - CD4 counts are Normal. ( >500/mm 3 ). - Longest phase (4-7 years).

9. ** Symptomatic HIV Infection ** - First evidence of Immune system dysfunction. - Lasts about 1-3 years -without TT-. The following frequently appear: - Generalized Lymphadenopathy. - Localized fungal infections, ( on fingernails, toes, mouth). - Recalcitrant vaginal yeast & trichomonal infections in women. - Oral hairy leukoplakia on the tongue. - Skin manifestations ; ( seborrheic dermatitis, molluscum, warts.) - Constitutional symptoms.

10. ** AIDS ** - Marked immune suppression, leads to disseminated opportunistic infections & malignancies. - CD4 count is <200 cells/mm 3. - Pulmonary, GI, neurologic, cutaneous & systemic symptoms are common.

12. ** Patients infected with HIV are at risk for illness and death from: 1) Opportunistic infections 2) Neoplastic complications ** HIV related Cancers: 1) Kaposi’s Sarcoma. 2) SCC of cervix & anus. 3) NHL.

16. - Clinic or Emergency Department.. - Introduce yourself, welcoming, polite - Patient Profile - Chief complaint - Hx of chief complain……..usually viral infection like manifestation.

17. Presenting Manifestations (Chief Complaint) -Fever -Sore Throat -Pharyngitis -Rash -Lymphadenopathy -Nausea -Vomiting -Diarrhea -Weight loss -Muscle Aches -Skin lesion -Night sweats -Genital infections -Recent respiratory tract infection -Headache

18. History **When you are taking history and suspecting HIV infection you should be: -serious -trustful -privacy -good listener -don’t judge So that the patient feels comfortable telling you anything private or he thinks its shameful…

19. The most IMP Qs you should ask your patient are: Sexual activity=> *if the ptn is sexually active recently? *how many partners? *female or male partners? *using protection? *is the partner having the same symptoms as the ptn? Previous infections? STDs?

20. - Mucous contact with infected blood. - E.g: needle stick injury - Needle sharing (drug abuse) - Blood transfusion or donation - Tattoo - Prior or current STDs (gonorrhea/ chlamydia infection/ syphilis/ herpes genitalis) - TB history/ contact

21. - Has the patient done any HIV test before ? If yes >> when? Why ? What was the result? - Travel history - Animal contact - Immunization history (BCG, Hepatitis A and B)

23. Physical Examination - There is no specific physical sign for HIV infection. - But there are some Signs of related diseases. - So, we do a Full Body physical Examination looking for a sign or finding to related diseases of HIV

24. General Observation - Weight Loss - Tachypnoea - Dry Cough - Generalised rash - Fever and Sweats - Nausea and Vomitting - Diarrhea - Muscle Aches - Sore Throat

25. Limbs And Face Seborrhoeic dermatitis

26. Secondary Syphilis

27. Herpes Zooster

28. Molluscum contagiosum

29. Kaposi’s Sarcoma

30. Oropharynx Oropharyngeal Candidiasis

31. Oral hairy leukoplakia

32. Herpes Simplex

33. Aphthous Ulcer

34. Kaposi’s Sarcoma

35. Neck Lymph Node Enlargement : *TB *Lymphoma Reactive Lymphadenitis

36. Eyes Kaposi’s Sarcoma

37. Jaundice

38. Syphilis

39. Cytomegalovirus Retinitis

40. CNS Progressive multifocal leucoencephalopathy

41. Toxoplasmosis

42. Primary CNS lymphoma

43. Chest - Dullness to percussion - Crepitations Abdomen -Hepatospleenomegally Anogenital Region - Rashes - Cancer - Condylomas - Herpes simplex

45. 1. PCR RNA viral load test : - Pt. with acute HIV infection >> have very high levels of Viremia. - This test is repeated to assess effectiveness of therapy. 2. p24 antigen assay : - Less costly. - Less Sensitive. -Alternative to viral load testing.

46. 3. Seroconversion : - occurs 3-7 weeks after infection. - confirms the diagnosis. Seroconversion ELISA -Screening test for detecting antibody to HIV. -Positive 1-12 Ws after infection, & western blot should be performed for confirmation. -A negative ELISA excludes HIV. (99% sensetive). Western blot test -Specific test. -Used to confirm a positive result on an ELISA test.

47. 4. Diagnosis of AIDS : a. Depends principally on the identification of an indicator condition OR on finding in an HIV- 1 – seropositive pt. a CD4 cell count lower than 200. b. There are many indicator conditions (AIDS- defining illnesses).

52. 1. Antiretroviral therapy : a. Indications: - Symptomatic pts, regardless of CD4 count. - Asymptomatic pts with CD4 count <500. b. Triple-drug regimens known as HAART : - To target & prevent HIV replications at 3 different points along the replication process. - Use 2 nucleoside reverse transcriptase inhibitors & either : ○ A non-nucleoside reverse transcriptase inhibitor. ○ A protease inhibitor. c. Monitor the response to treatment using Plasma HIV RNA load, the goal is to reduce the viral load to undetectable levels. d. It is recommended that HAART therapy be continued in pregnant pts with HIV.

53. 2. Opportunistic infection prophylaxis : a. Pneumocystic Pneumonia (PCP) : - formerly P.carinii, Now named P. jiroveci. - Occurs in pts with AIDS when CD4 cell count <200 & pt isn’t on prophylaxis. - TMP/SMX (co-trimoxazole ) is the preferred agent. b. TB : - Screen all pts with a yearly PPD test. - If the pts has positive PPD, prescribe isoniazid + pyridoxine

54. c. Atypical mycobacteria – (MAC) : - Start prophylaxis when CD4 cell count <100. - Prophylatic agents : Clarithromycin + Azithromycin. d. Toxoplasmosis : - Give this to pts wieh CD4 count <100. - TMP/SMX (co-trimoxazole) is the preferred agent.

55. - NO live-virus vaccine. - Pneumococcal polysaccharide vaccine ( Pneumovax) : every 5-6 years. - Influenza vaccine : yearly. - Hepatitis B vaccine ( if NOT already Antibody-positive)