1. Acquired Immuno-deficiency Syndrome (AIDS)
Dr. Assad Rahhal
National AIDS Program/ MOH

2. Definition
AIDS is a chronic, life-threatening condition caused by the human immunodeficiency virus (HIV). By damaging immune system, HIV interferes with the body's ability to fight off viruses, bacteria and fungi that cause disease. HIV makes man more susceptible to certain types of cancers and to infections which the body would normally resist.
The virus and the infection itself are known as HIV. AIDS is the name given to the later stages of an HIV infection

3. Infectious agent: HIV 1, HIV 2 Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte

4. Symptoms Early infection (window period) Fever Headache Sore throat
Swollen lymph glands
Rash
Later infection (advanced HIV infection)
Swollen lymph nodes — often one of the first signs of HIV infection
Diarrhea
Weight loss
Cough and shortness of breath

5. Relationship between HIV copies (viral load) and CD4 counts over the average course of untreated HIV infection
CD4+ T Lymphocyte count (cells/mm³)
HIV RNA copies per mL of plasma

6. Symptoms Latest phase of infection (AIDS)
In 1993, the Centers for Disease Control and Prevention (CDC) redefined AIDS to mean the presence of HIV infection as shown by a positive HIV-antibody test plus at least one of the following:
The development of an opportunistic infection — an infection that occurs when immune system is impaired — such as Pneumocystis carinii pneumonia (PCP)
A CD4 lymphocyte count of 200 or less — a normal count ranges from 800 to 1,200

7. Symptoms Latest phase of infection (AIDS) Soaking night sweats
Shaking chills or fever higher than 38 C for several weeks
Dry cough and shortness of breath
Chronic diarrhea
Persistent white spots or unusual lesions on the tongue or in mouth
Headaches
Blurred and distorted vision
Weight loss

8. Transmission Sexual transmission Infected blood needle sharing
accidental needle sticks
tattoo, body piercing
organ or tissue transplants or unsterilized dental or surgical equipment.
Mother to child

9. Risk factors Anyone of any age, race, sex can be infected with HIV
unprotected sex with someone who is HIV-positive (multiple partners, heterosexual, homosexual or bisexual). Unprotected sex means having sex without using a new latex or polyurethane condom every time.
Have another sexually transmitted disease, such as syphilis, genital herpes, chlamydia, gonorrhea or bacterial vaginosis.
Sharing needles during intravenous drug use.
Have fewer copies of a gene called CCL3L1 that helps fight HIV infection.

10. Complications Bacterial infections: Bacterial pneumonia
Mycobacterium avium complex (MAC). This infection is caused by a group of mycobacteria, in advanced HIV infection and when CD4 lymphocyte count is less than 50, it is more likely to develop a systemic infection that can affect almost any internal organ, including bone marrow, liver or spleen
Tuberculosis (TB): the most common infection associated with HIV and a leading cause of death among people living with AIDS
Salmonellosis
Bacillary angiomatosis (Bartonella henselae): purplish to bright red patches on skin

11. Complications Viral infections:
Cytomegalovirus (CMV): damage to eyes, digestive tract, lungs or other organs. Most commonly, CMV causes infection and inflammation of the retina (CMV retinitis)
Viral hepatitis
Herpes simplex virus (HSV)
Human papillomavirus (HPV): one of the most common causes of sexually transmitted diseases (warts on the genitals)
Progressive multi-focal leuko-encephalopathy (PML): human polyomavirus JC virus, speech problems, weakness on one side of the body, loss of vision in one eye, or numbness in one arm or leg

12. Complications Fungal infections: Parasitic infections: Candidiasis
Cryptococcal meningitis: caused by a fungus that is present in soil, it may also be associated with bird or bat droppings
Parasitic infections:
Pneumocystis carinii pneumonia (PCP): one of the most common opportunistic infections affecting PLWHA
Toxoplasmosis: caused by Toxoplasma gondii, a parasite spread primarily by cats. For many people with AIDS, toxoplasmosis leads to encephalitis
Cryptosporidiosis: leads to severe, chronic diarrhea in people with AIDS.

13. Complications Cancers: Other complications Kaposi's sarcoma
Non-Hodgkin's lymphoma
Other complications
Wasting syndrome: it is defined as a loss of at least 10 percent of body weight and is often accompanied by diarrhea, chronic weakness and fever.
Neurological complications: confusion, forgetfulness, changes in behavior, depression, anxiety and trouble walking. One of the most common neurological complications is AIDS dementia complex, which leads to behavioral changes and diminished mental functioning

15. Kaposi sarcoma

16. Tests and diagnosis
WHO disease staging system(1990, update in September 2005):
Stage I: HIV infection is asymptomatic and not categorized as AIDS
Stage II: includes minor mucocutaneous manifestations and recurrent upper respiratory tract infections
Stage III: includes unexplained chronic diarrhea for longer than a month, severe bacterial infections and pulmonary tuberculosis
Stage IV: includes toxoplasmosis of the brain, candidiasis of the esophagus, trachea, bronchi or lungs and Kaposi's sarcoma; these diseases are indicators of AIDS.

17. Tests and diagnosis
HIV is diagnosed by testing your blood or oral mucus for the presence of antibodies to the virus
Enzyme-linked immunosorbent assay (ELISA) and Western blot tests (checks for the presence of HIV proteins)
Rapid tests
Home tests
Viral load: used to decide when to start and when to change treatment

18. WHEN TO START ARV THERAPY ?
Clinically advanced HIV disease:
WHO Stage IV HIV disease, irrespective of the CD4 cell count;
WHO Stage III disease with consideration of using CD4 cell counts <350/mm3 to assist decision-making
WHO Stage I or II HIV disease with CD4 cell counts <200/mm3

19. Factors considered in the selection of ART regimens
potency;
side-effect profile;
laboratory monitoring requirements;
potential for maintenance of future treatment options;
anticipated patient adherence;
coexistent conditions (e.g. coinfections, metabolic abnormalities);

20. Factors considered in the selection of ART regimens
pregnancy or the risk thereof;
use of concomitant medications (i.e. potential drug interactions);
potential for infection with a virus strain with diminished susceptibility to one or more ARVs, including that resulting from prior exposure to ARVs given for prophylaxis or treatment;
very importantly, availability and cost.
The use of quality-assured a antiretroviral in fixed-dose combinations

21. Treatments and drugs
Improve quality of life, none of drugs can cure HIV/AIDS
Treatment should focus on achieving the maximum suppression of symptoms for as long as possible (highly active anti-retroviral therapy HAART)
Anti-retroviral drugs:
Nucleoside analogue reverse transcriptase inhibitors (NRTIs):
inhibit the replication of an HIV enzyme called reverse transcriptase (zidovudine, lamivudine, didanosine, stavudine, abacavir, emtricitabine
Protease inhibitors (PIs): interrupt HIV replication at a later stage in its life cycle by interfering with an enzyme known as HIV protease (saquinavir ritonavir, indinavir, nelfinavir, amprenavir, lopinavir/ritonavir (Kaletra), atazanavir and tipranavir. PIs are usually prescribed with other medications, to help avoid drug resistance.

22. Treatments and drugs Anti-retroviral drugs:
Non-nucleoside reverse transcriptase inhibitors (NNRTIs): bind directly to the enzyme reverse transcriptase (nevirapine, delavirdine, efavirenz and etravirine)
Nucleotide reverse transcriptase inhibitors (NtRTIs): interfere with the replication of reverse transcriptase and prevent the virus from inserting its genetic material into cells (tenofovir)

23. FIRST-LINE ARV REGIMENS IN ADULTS AND ADOLESCENTS
Usage in women (of childbearing age or pregnant
Major potential toxicities
*ARV regimen
Yes
d4T-related neuropathy, pancreatitis and lipoatrophy;
NVP-related hepatotoxicity and severe rash
Stavudine (d4T)/
Lamivudine (3TC)/
Nevirapine (NVP)
ZDV-related GI intolerance, anemia, and neutropenia;
Zidovudine (ZDV)/
3TC/NVP No
EFV-related CNS toxicity and potential for teratogenicity
d4T/3TC/
Efavirenz (EFV)
ZDV-related GI intolerance, anemia and neutropenia;
ZDV/3TC/EFV
*2 NRTIs + 1 NNRTIs

24. Stages of the epidemic Low Grade Concentrated Generalized
Prevalence of HIV is consistently below 5% in any “high risk groups” and below 1% in the “general population”
Concentrated
Prevalence of HIV has surpassed 5% on a consistent basis in one or more “high risk groups” but remains below 1% in the “general population”
Generalized
Prevalence of HIV has surpassed 1% in the “general population”

25. Estimated per act risk for acquisition of HIV by exposure route
Estimated infections per 10,000 exposures to an infected source
Exposure Route
6.5
Insertive anal intercourse
9000
Blood Transfusion 10
Receptive penile-vaginal intercourse
2,500
Childbirth 5
Insertive penile-vaginal intercourse 67
Needle-sharing injection drug use 1
Receptive oral intercourse 30
Percutaneous needle stick .5
Insertive oral intercourse 50
Receptive anal intercourse

26. Life expectancy in some Southern African countries/ 1958 - 2003

27. Prevention and control
Prevention programs:
Health education: public, schools
Abstain, Be faith, and Condom use (ABC)
Treatment and rehabilitation of IDUs, harm reduction and needle exchange programs
VCT services, BCC, MARPs programs
Blood safety and universal precautions
PMTCT
Male circumcision
Immunization of infected children (no BCG for symptomatic)

28. Prevention and control
Comprehensive STIs treatment and care
Care and support for PLWHA
Reporting of cases
Notification of contacts and source of infection (confidentiality)
Provision of treatment, tuberculin test
Viral load and CD+4 T cell count