1. Dr Emmanuel Nsutebu Consultant Infectious Diseases Physician Tropical and Infectious Diseases Unit Royal Liverpool Hospital HIV “Myths, controversies and challenges”

2. “10 questions....” 1. What is the difference b/w HIV and AIDS 2. What is the origin? 3. How is it transmitted? 4. Does the risk of transmission vary? 5. Can you know when a person got infected? 6. Is lengthy pretest counselling needed before a test is done? 7.How is HIV treated? 8. Can it be cured? 9. What is the life expectancy? 10. What about a vaccine and is there hope?

3. How many people are affected?  Globally 34 million PLHAs, 1.7M deaths a year, 2.5M new infections a year  15 million eligible for treatment and 8 million on treatment.  24 million cases in Africa  5% adult prevalence in Cameroon (2011) – 900000 PLHA  UK – 70000 PLHA  No. Of new cases and deaths Falling due to success of treatment

4. 1. What is the difference b/w HIV and AIDS? Not the same thing but related. AIDS is a stage of HIV infection.

5. NOT ALL HIV INFECTION = AIDS

6. Most people with HIV have no symptoms

7. 2. Origin? Jump from chimpanzees to humans - SIV

8. Figure 1 Source: The Lancet Infectious Diseases 2011; 11:45-56 (DOI:10.1016/S1473-3099(10)70186-9)The Lancet Infectious Diseases 2011; 11:45-56 Terms and Conditions

9. 3. How is HIV transmitted? Unprotected sex – 70% of infections Mother to child transmission – mum must be positive – during pregnancy, at birth or during breastfeeding! Intravenous drug use – sharing needles Blood transfusion and other blood products Medical equipment

10. Mother to child transmission 30% risk of transmission reduced to <2% with ARVS

11. How is HIV not transmitted? Cutlery Mosquitoes Kissing Hugging

12. 4. Does the risk of transmission vary? Varies depending on Positive person Negative person Route of transmission Sex 3/1000 but can happen with first contact Transmission to women easier IV drug user high risk

13. 5. Can you know when a person acquired the infection? No but can guess!!!

14. June 15 Understanding HIV Treatment and adherence. 4-8 wks Up to 12 years 2-3 years No symptomsSymptoms AIDS Death 1000 50 0 0 CD4 count HIV viral load 200 2-12 mo 2 million 0 Viral load & CD4 after HIV Infection [without treatment ] Time

15. HIV infection J. Coffin, XI International Conf. on AIDS, Vancouver, 1996 Development of AIDS is like an impending train wreck Viral Load = Speed of the train CD4 count = Distance from cliff

16. Infections and cancer!

17. 6. Is lengthy pretest counselling needed? An HIV test is a routine test!!!

18. 7. How is HIV treated and it is effective?

19. HIV Replication Cycle and Sites of Drug Activity clinicaloptions.com/hiv Capsid proteins and viral RNA CD 4 Receptor Viral RNA New HIV particles Protease Attachment UncoatingReverse Transcription IntegrationTranscription Translation Reverse Transcriptase Unintegrated double stranded Viral DNA Integrated viral DNA Viral mRNA Integrase gag-pol polyprotein 1 2 34 5 6 Assembly and Release Protease Inhibitors NRTIs NNRTIs Nucleus Cellular DNA CCR5 or CXCR 4 co-receptor HIV Virions nRTI Fusion Inhibitors At least 3 drugs to stop the virus from multiplying

20. HIV Medication Timeline Between ’87 and ’95 (9 years), 4 antiretrovials were launched. Since ’95 (11 years), 25 new products have been introduced!! NNRTI ’87’91’92’94’95’96’97’98’99‘00’88’89’90 NRTI FI saquinavir indinavir Kaletra zalcitabine stavudine ’01 emtricitabine/tenofovir enfuvirtide ‘02‘04 ’93 amprenavir ‘05‘06‘03 zidovudine emtricitabine abacavir/ lamivudine/ zidovudine lamivudine/zidovudine delavirdine nevirapine abacavir efavirenz tenofovir ritonavir saquinavir atazanavir fosamprenavir nelfinavir darunavir tipranavir PI didanosine didanosine Corrections Curriculum Development, NY/NJ AETC lamivudine Many drugs available and more in development – outlook is good!

21. Treatment & Treatment as prevention Most patients on one or two tablets a day!

22. June 15 Understanding HIV Treatment and adherence. After HIV treatment (ARVs): effect on CD4 and viral load 1-12 yrs+1-6 mo Chronic Infection Start treatment 1000 50 0 0 CD4+ cells/mm3 viral load (RNA) copies/mL 200 2 million 0 + 1-40+ years !! < 50 copies/mL Viral load <50 copies/mL Time

23. 8. What is life expectancy like? We don’t know for sure however we have estimates.... HIV survival similar to other chronic diseases! Life expectancy at 25 years diagnosis estimated to be 70 years

24. 9. What about a cure?

25. 10. What about a vaccine? Problem is variability of the virus!!! Stays one step ahead of immune system!!!

26. What are challenges? Early diagnosis Access to treatment in developing countries

27. Thank you nsutebufru@hotmail.com