1. The global epidemic of HIV infection Ford von Reyn Infectious Disease Section Dartmouth-Hitchcock Medical Center

3. AIDS at DHMC u 7/15/81 33 yo gay man, IDU Admitted with bilateral pulmonary infiltrates Dx: Pneumocystis carinii pneumonia (PCP) Rx: Died after 16 days CDC: 30-35 cases reported

4. Rock Hudson reported with AIDS-1985

6. -1986

7. Global estimates for adults and children end 2003 u People living with HIV/AIDS u New HIV infections u Deaths due to HIV/AIDS 46 million 5 million 3 million

8. Adults and children estimated to be living with HIV/AIDS as of end 2001 Western Europe 550 000 North Africa & Middle East 500 000 Sub-Saharan Africa 28.5 million Eastern Europe & Central Asia 1 million South & South-East Asia 5.6 million Australia & New Zealand 15 000 North America 950 000 Caribbean 420 000 Latin America 1.5 million Total: 40 million East Asia & Pacific 1 million

10. Modes of transmission of HIV u Sexual u Parenteral u Perinatal

11. Global transmission patterns Pattern I: developed countries (e.g. US, Australia, W Europe) u Sexual: homosexual>heterosexual u Parenteral: injecting drug use u Perinatal: perinatal/postnatal>prenatal Seroprevalence: >F)

12. Global transmission patterns Pattern II: developing countries (e.g. sub-Saharan Africa) u Sexual: heterosexual (M=F) u Parenteral: unsterile needles, transfusion u Perinatal: perinatal/postnatal>prenatal Seroprevalence: 1-25%(M=F)

16. Modes of transmission of HIV u Sexual u Parenteral u Perinatal

25. Heterosexual Transmission: Uganda u 415 couples with HIV pos and HIV neg partner u Up to 30 month follow with counseling u Seroconversion in 90 couples (12/100 py) u No difference in M to F vs F to M transmission u Role of circumcision l seroconversion 16.7/100 py in uncircumcised males l seroconversion 0/100 py in circumcised males u Role of viral load: seroconversion 0/100 py in 51 patients with viral load <1500 -Quinn 2000

27. Sexual transmission of HIV u Transmission is bidirectional M F = F M u Rate of transmission per episode intercourse: 1/1000 long term partner: 15-25% u Risk factors: viral load lack of circumcision genital ulcers

29. Modes of transmission of HIV u Sexual u Parenteral u Perinatal

34. Modes of transmission of HIV u Sexual u Parenteral u Perinatal

35. Perinatal Transmission of Human Immunodeficiency Virus (HIV) Prenatal(7%)-Transplacental Intrapartum(13%)-During delivery Postpartum (14%)-Breast feeding Mofenson 2001

36. AIDS as a zoonosis Simian immunodeficiency viruses Pan troglodytes SIVcpz (chimpanzee) Sooty mangabeys SIVsm -Hahn 2000, Science

49. Tuberculosis Risk:active TB = 5% in reported AIDS cases reactivation 7%/yr Mortality:low (unless MDR) CD4 range:all, median = 354 (US, Theuer) Surveillance:annual PPD skin testing (read by provider) Prevention:childhood BCG (developing countries) INH 300 mg+pyr 50 mg x 12 mos for PPD > 5mm anergic patients at high risk (e.g. IDU)

50. Pneumocystis carinii Pneumonia Risk:80% cumulative risk Mortality:15% per episode CD4 range:usually <200, (10% higher, most <50) Prevention:for CD4<200 or any OI (e.g. thrush), give TMP/SMZ DS (160/800) 3x/wk or Dapsone 100 qd or 50 bid or Aerosol pentamidine 300/mo

52. Malignancies in HIV 1. Kaposi’s Sarcoma Tumor due to sexually acquired HHV-6. Cutaneous or mucous membrane involvement most common but may have primary lesion in GI tract. 2. Lymphoma Most are B cell and extranodal, esp brain and abdominal mesentary 3. Anorectal Tumors Squamous cell tumors of the anus and rectum in gay men

56. Treatment of HIV u Highly active antiretroviral therapy (HAART) u Reduces viral load, increases CD4 and prolongs survival u Side effects are significant

58. Pseudoobesity Abdominal visceral fat accumulation appearing within 7 months of treatment N Engl J MED 1998;339:1296

59. Peripheral Lipoatrophy, Leg Loss of subcutaneous fat in the legs, leading to abnormally visible veins and muscles. Btrtish J Derm 2000;142:496-500

60. Peripheral Lipoatrophy, Face Wasting of the buccal fat, giving a pseudocachectic appearance. Btrtish J Derm 2000;142:496-500

62. Prevention of HIV infection u Sexual: counselling and testing, education, condom distribution u Parenteral: blood screening, needle safety, needle exchange treatment for drug abuse u Perinatal: screening, antiviral prophylaxis u Vaccine: challenging

63. -Furtado 1999 NEJM