HIV and HIV counselling

Edit this Article | Original article by Tom Leach |

Last updated on 24/5/204 | Vie! "e#isions
In This Article
E pidemiology
Transmission
Pathology
Clinical features
Diagnosis
Monitoring
Management
Principles of therapy
Prevention
Counseling for HIV testing
Postterm counseling
Epidemiology
40 $illion cases !orld!ide
Incidence ! 5$/year
Deaths ! %$/year
Prevalence of AID" &%$illion
'ost o( these are !o$en and children in A(rica
Types of virus
o HIV) * the $ost pre#alent type in Europe
o HIV)2 causes a si$ilar disease+ but has a
longer latency period
#$ incidence ! 7500/year
'ore co$$on in heterose,ual indi#iduals than
ho$ose,ual indi#iduals since ---.

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Transmission
"e%ual
/50 se,ual intercourse
5)/0 oral se,
Evidence suggests that circumcision reduces the
risk of infection by 60% - however there is some
public belief that it provides immunity it does
not!
Risks (per sexual encounter):
Anal se, * recei#ing partner * bet!een 0. *
%0
Anal se, * acti#e partner ) 10.0
Vaginal se, * (e$ale * in 00+000
Vaginal se, * $ale * in 200+000
Oral se, * less than in 200+000
2hild birth * &'(
2hild birth 3 breast (eeding * )'(
*lood products
IV drug use
Vertical transmission

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Pathology
HIV is an RN retrovirus! 4he #irus is incorporated
into a host cell+ !hereby+ the #iral
en5y$e transcriptase !ill begin transcription o( the
"6A to 76A. 4hen+ the #iral en5y$e inte"rase !ill
integrate the 76A into the host8s.
4he host cell !ill then produce #iral
polypeptides+ !hich are clea#ed into (unctional #iral
parts by the #iral en5y$e protease!
9inally+ co$plete #irions are released by the
host cell #ia budding
Infection of cells 4hese ne! #irion can no! in(ect
ne! cells. 4hey are capable o( entering any cell
that e#presses the $%& receptor! 4he #irus !ill
bind to 274 receptors !ith the gp&)+
glycoprotein, :usceptible cells include;
2743 4 cells
'acrophages
'onocytes
6eurons
2743 4 cells !ill $igrate to ly$phoid tissue+ and
release $illions o( #irons+ ready to in(ect ne! cells.
As the in(ection progresses+ destruction o( 2743
cells leads to reduced e((icacy o( the host i$$une
syste$.

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Clinical features
HIV in(ection can be di#ided into stages;
"eroconversion ! typically occurs 2)< !ee=s a(ter
e,posure. Is o(ten asy$pto$atic+ but in so$e
indi#iduals there $ay be a period o( (e#er+ $alaise+
$yalgia+ pharygnitis and $aculopapular rash.
Asymptomatic infection ! this can last (or years
0% of patients !ill have a persistent
"enerali'ed lymphadenopathy ()*+, !here
there are lymph nodes "cm in diameter at #$ extra-
inguinal sites% &his may last # months%
AID" related comple% -A.C/ ! this is a set o(
prodro$al sy$pto$s that precedes the onset o(
AI7:. It can include;
Opportunistic in(ection >e.g. candidal
in(ection+ herpes etc?
6ight s!eats
High te$p
7iarrhoea
AID"
4here is $ar=ed i$$unode(iciency
4ypically de(ined as a 274 count 1200 , 0
<
/ L

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Diagnosis
P)0 antigen ! present in the blood in the (irst %
$onths o( in(ection. @sually le#els drop by the ti$e
IgA and Ig' are produced >% $onths?. Le#els rise
again as i$$unode(iciency de#elops.
HIV .1A ! can also be detected using B2"
techniCues during the early stages o( the in(ection
@sed to $onitor progress and e((ecti#eness o(
treat$ent >:ee belo!?
Ig2 and IgM ! le#els detectable a(ter %
$onths. 9all as i$$unode(iciency de#elops >try
loo=ing (or B24?.
-ra.uick is a method of detecting '()
antibodies in saliva% *ast and easy+ but high false
positives%
HIV and T* ! o(ten co)e,ist+ and can be a real
proble$.
%0)500 o( those !ith AI7: also ha#e 4D
'antou, test can be negati#e e#en in positi#e
patients
4D presentation is o(ten atypical
A3* >Acid)(ast bacilli? "mear ! $ay be
negati#e+ or ha#e #ery (e! cells. I$portant to
culture (or sensiti#ities.
All HIV positive patients should 4e regularly
monitored for T*, :o$e reco$$end the use
o( isonia'id as prophyla,is in HIV positi#e patients.

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Monitoring
4he (ollo!ing should be $easured every /
months;
HIV .1A levels ! strongly predict the progression
to AI7:+ re"ardless of the $%& count!
Batients can be Estaged8 according to HIV "6A
le#els+ e.g.;
4hose in the lo!est Cuartile ha#e an F0 o(
progressing to AI7: in 5 years+ co$pared to <20 o(
those in the highest Cuartile.
CD0 count
(n the developing !orld+ this test may be too
expsenive% , total lymphocytes count may be
ade-uate
&otal lymphocytes . "/00+ then 01/ roughly
.$00
&his is accurate enough for predicting '()
progression
Viral load

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Management
All ne!ly diagnosed HIV positi#e patients should be
tested (or;
T*
To%oplasma
CMV
Hepatitis * 5 C
"yphilis

HAA.T ! highly active anti-retroviral therapy
In the de#eloped !orld+ this is the $ainstay o(
treat$ent. 0here is not one specific
recommended re"imen essentially all regi$ens
are e,peri$ental co$binations o( anti)retro#iral
drugs
1t aims to reduce the rate of viral replication
below detectable levels! 4his does not $ean that
replication is not occurringG
HAA"4 should be part o( a holistic care
approach.
It is a co$bination o( t!o 1uceloside
analogue reverse transcriptase
inhi4itors >6"4I8s?+ PL#"
o Either2 a Protease Inhi4itor -PI/6
o 3r2 a nonnucleoside reverse
transcriptase inhi4itor >66"4I?

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Principles of therapy
al!ays use &% drugs >don8t do double therapy?
4tart treatment as early as possible 5 i.e. be(ore
274 count 1200
2hen to start treatment3
Any patient !ith AI7:
Any patient !ith 274 1200
o 2ill probably be revised upwards
soon (6$78-00)
Any patient !ith 274 200)%50 !ith high #iral load
Any patient !ith 274 200)%50+ but 274 (alling (ast
Ad#ise the patient that regi$ens are co$ple,+
and reCuire strict adherence
Monitor Viral load and CD0 count regularly,
Ideally+ viral load will be undetectable after &
months of 4R0
I( #iral load is apparently erratic+ consider poor
adherence
I( (iral load re$ains high despite treat$ent+
change the regi$en

1.TI7s ! e.g. 8idovudine6 Didanosine6
Lamivudine6 Emtricita4ine6 Tenofovir6 A4acavir
:ide e((ect are not particularly pleasant+ and
include;
naemia5 leucopaenia5 *1 disturbance5
rashes5 myal"ia5 neuropathies5 pancreatitis!
CI7s9 L94 disturbance+ Hepato$egaly+ lactic
acidosis+ breast (eeding+ anae$ia. 'onitor
(or li#er proble$s and a$ylase.

Protease Inhi4itors ! e.g. Indinavir6 .itonavir6
"a:uinavir6 Lopinavir
:lo! the #iral spread+ prolong the
asy$pto$atic stage o( the disease
'etaboli5ed y cytochro$e B450 syste$ * so
can cause drug interactions
2an cause metabolic syndrome >insulin
resistance+ hyperglycae$ia+ dyslipidae$ia?
:ide e((ects; Taste distur4ance6 rash6
pruritus >itch?+ hyperpigmentation6 alopecia6
parasthesia6
myalgia6 headache6 di;;iness6 pancreatitis6 anae
mia6 a4normal L3Ts,

11.TI7s e.g. 1evirapine6 Efaviren;
Again+ in#ol#ed !ith cytochro$e B450
"esistance occurs Cuic=ly
"ide effects
Hepatitis+ di55iness+ avoid in pre"nancy!

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Prevention
PEP ! post-exposure prophylaxis 5 anti HIV drugs
can be ta=en as prophyla,is+ i( ta=en !ithin /2
hours o( e,posure to HIV. 4his e,posure could be in
the (or$ o( se,ual contact >including oral+ #aginal+
anal?+ or blood products contact.
1eedlestic< in=uries
.is< of HIV infection is >+,'(
o 4ests (or HIV antibodies should be done at
%+< and F $onths to chec= (or serocon#ersion
"is= o( Hep D in(ection is about %00
6ake it bleed!
o Dut do not suc=+ or put in bleech
Aet the details o( the Edonor8
"eport to occupational health A:AB
:tore blood sa$ples (ro$ both parties
$heck risk
o "elated to the donor 274 le#el and #iral
load
$onsider prophyla#is
o 9o! risk 5 may not be needed
o 'igh risk 5 'idovudine $80mg : "$h
; lamivudine 50$g / 2h 3 indinavir F00$g / Fhr+
all BO
o Do a pregnancy test 4efore starting on
prophyla%is?
o &here have been about "00 cases
!orld!ide+ and 8 in the <=+ of a healthcare !orking
contracting '() from a patient

Prevention of vertical transmission
50 ris= o( #ertical trans$ission >higher in A(rica?
Methods of prevention o( #ertical trans$ission;
All HIV positive mothers should
4a=e anti)retro#irals * nevirapine is
reco$$ended. I( on another agent
be(ore pregnancy+ s!itch to this once pregnant
2onsider 2aesarian
<sually elective caesarean at > !eeks
)aginal delivery is a ?* 5 if t!ins+ the first t!in
is at greater risk of vertical transmission
Abstain (ro$ breast (eeding
I( all the abo#e $easures are adhered to+ ris=
o( trans$ission is about )(,
Ha#e tests (or genital in(ection at boo=ing and
at 2F !ee=s

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Counseling for HIV testing
It is #ery i$portant to re$e$ber that before you
perform an 417 test you need to tell the patient
about the i$plications o( a positi#e result. @ou
should9
7eter$ine the le#el o( ris= >e.g. unprotected se,+
nu$ber o( partners+ se, o#erseas?
7iscuss the bene(its o( =no!ing i( test is positi#e;
@rotect partner
?educe risk of vertical transmission
Aet treatment
sk about ma8or concerns e.g.;
4elling partner / (riends
Hob
'ortgage >i( can8t !or=?
2on(identiality
9ou don:t have an obli"ation to inform the
partner as this !ould brea= con(identiality.
Encourage patient to discuss these issues !ith
partner * o((er the$ to in#ite partner along to
surgery i( this !ould help.
4owever i( the patient re(uses to tell their
partner+ you should consult A@' specialists /
'7@ / 'B: to discuss the cases. In so$e
instances it $ay be acceptable to brea=
con(identiality to in(or$ those at ris=.
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Postterm counseling
Again discuss e((ects on (a$ily+ Iob+ telling
partner / (riends
E$phasi5e $ethods to reduce e,posure.
+on";term counselin" may involve making
plans for death+ e%g%
o Baking a !ill
o 'ousing
o Employment
o 0are of children
o (nvolvement of A@+ palliative care
services+ and '() experts
) :ee $ore at;
http;//al$ostadoctor.co.u=/content/syste$s/obstetric
s)and)gynaecology/stds)and)other)genitourinary)
disorders/hi#)and)hi#)
counseJsthash.IgK6,"6L.dpu(