immune system dysfunction which predisposes patients to various opportunistic infections and malignancies.
AIDS (Acquired Immune Deficiency Syndrome)
is related to HIV. A person has AIDS only in the final stages of HIV, after the immune system becomes unable to defend itself against foreign invaders like bacteria, other viruses, and allows the development of certain cancers. Types
HIV-1 and HIV-2
Both are transmitted via the same routes and
lead to AIDS but HIV-2 is generally less virulent HIV-1 is the predominant type in North America and most of the world. HIV-2 is found mainly in West Africa. It is less easily transmitted and develops more slowly Incidence
Since 1981 1.7 million people in the United States alone
are estimated to have been infected with HIV. The Caribbean is the second-most affected region in the world in terms of HIV prevalence rates. Based on 2009 data, about 1.0 percent of the adult population (240,000 people) is living with the disease, which is higher than any other region except Sub-Saharan Africa. 1 in 5 of those infected are unaware. MSM (Men who have sex with men ) accounted for 61% of all new HIV infections in the U.S. in 2009. Over 619,000 with HIV have already died since the epidemic began. Aetiology
The early 1980s introduced us to HIV/AIDS.
The most likely theories assume that HIV-1 was
transmitted to humans from chimpanzees sometime in the early 20th century. Natural History
Acute (Infection) Retroviral Syndrome
2-6 weeks post exposure: 40-90% experience an acute "flu-like" illness lasting 10-15 days; may include fever, pharyngitis, lymphadenopathy, rash, arthralgias, myalgias, GI symptoms, oral ulcers, weight loss. Heamatologic disturbances; lymphopenia, thrombocytopenia. 10-20% present with aseptic meningitis; HIV RNA and/or p24 may be detected in CSF associated with a high level of plasma viremia and therefore high risk of transmission Stage II
Asymptomatic (Latent) Stage
HIV active and reproducing at low levels in CD4+ T lymphocytes. CD4 count drops 60-100 cells/mm3 per year (N: 500-1,100) 10 years post-infection: 50% have AIDS, 30% demonstrate milder symptoms, <20% are asymptomatic if left untreated Stage III
AIDS Definition in United States
CD4+ T-lymphocyte count of <200 cells/L OR CD4+ T-lymphocyte percentage of total lymphocytes of <14% OR documentation of an AIDS-defining condition Most severe stage of infection Increased number of opportunistic infections. If no treatment average survival is 3 yrs Natural History
Severity of disease is determined by:
Amount of virus in the body (virus load) Degree of immune suppression (CD4 count)
The higher the viral the load the sooner the
immune suppression. Virus attacks CD4 white blood cells Ability to fight infections lost Opportunistic diseases occur CD4 count Clinical Features/Symptoms CD4 count tresholds <500cells/mm3 for classic clinical Often asymptomatic presentations. Constitutional weight loss symptoms: fever, night sweats, fatigue,
Mycobacterium avium complex (MAC) Bacillary angiomatosis (disseminated Bartonella) Primary central nervous system lymphoma (PCNSL) Laboratory HIV-Related Opportunistic Disease Mode of Transmission HIV Invasion Site Sub-Location Transmission Medium Female genital tract Vagina, ectocervix, semen endocervix Male genital tract Inner foreskin, penile Cervicovaginal and urethra rectal secretions and desquamations
Intestinal tract Rectum Semen
Upper GI tract Semen Maternal blood/genital secretions Breast milk Placenta Chorionic villi Maternal blood Blood stream Contaminated blood products Sharp/needlestick injuries Mode of Transmission
HIV cannot be transmitted by:
Saliva (coughing, sneezing) and tears not mixed with blood, Insect bites (mosquitoes), Skin contact without broken skin (touching, hugging), Sharing dishes, water, food. Sharing toilets, telephones. Prevention of Transmission Public Health Strategies Screen all blood and blood products Educate the public on safer sex practices Identify and treat STIs Provide referral for treatment of drug dependence or resistance Apply PMTCT approach to prevent perinatal Transmission Awareness of spread via used needles and syringes Diagnosis
HIV TESTING AND COUNSELLING
RECOMMENDATION
WHO GUIDELINES Diagnosis
To be tested for HIV you usually give a sample
of blood, urine or a swab of fluids from your mouth WHO GUIDELINES FOR HIV TESTING WHO 5 Cs of HTC: Consent Confidentiality Counselling Correct results Linkage to Care Key Populations at Risk
Men who have sex with men
People in prisons and other closed settings People who inject drugs Sex workers Transgender people Unaware of HIV status. It is estimated that, globally, about half of the people currently living with HIV do not know their HIV status . For people from key populations, access to HTC and, thus, knowledge of HIV status tend to be much less. People from key populations often test late and often fail to link from HTC to care and assessment for ART . Thus, many start treatment when already significantly immunocompromised, when poor health outcomes and, for pregnant women presenting late in antenatal care or at delivery, vertical HIV transmission are more likely.
Counselling is an essential component of testing. Pre-test
counselling must provide accurate information about the test and the implications of a positive or negative result in order to enable the person seeking testing to make an informed choice. Post-test counselling must offer, among much else, support concerning disclosure of HIV status. Also, HTC offers a valuable opportunity to provide accurate information about safer sex and harm reduction that is relevant to the person being tested, reflecting the test result. Behavioural change and risk reduction counselling may also have value. Multiple settings. Rapid HIV testing enables health workers to provide clients with same-day results. Thus, HTC can be offered in a variety of settings, including primary care clinics (e.g. maternal, neonatal and child health clinics), and by a variety of providers, including outreach workers.
Community-based testing, linked to prevention, care and
treatment, has the potential to reach greater numbers of people than clinic-based HTC particularly those unlikely to go to a facility for testing and those who are asymptomatic. It is important to have clear procedures in place, following national HIV testing strategies and algorithms, to confirm positive HIV test results and to link clients to treatment and care. Recommendations and Guidelines ALL KEY POPULATION GROUPS Voluntary HTC should be routinely offered to all key populations in both the community and clinical settings. Community-based HIV testing and counselling for key populations, with linkage to prevention, care and treatment services, is recommended, in addition to provider-initiated testing and counselling . Additional remark Couples and partners should be offered voluntary HTC with support for mutual disclosure . Related recommendations and contextual issues for specific key population groups PEOPLE IN PRISONS AND OTHER CLOSED SETTINGS It is important to guard against negative consequences of testing in prisons for example, segregation of prisoners and to respect confidentiality. It is also important that people who test positive have access and are linked to HIV care and treatment services HIV testing and counselling should be voluntary. The use of HIV rapid testing can increase the likelihood of prisoners receiving their results. Testing in conjunction with other risk-reduction services such as the provision of condoms with lubricants and STI screening can increase the benefits of testing and counselling. ADOLESCENTS FROM KEY POPULATIONS In all epidemic settings accessible and acceptable HTC services must be available to adolescents and provided in ways that do not put them at risk. Countries are encouraged to examine their current consent policies and consider revising them to reduce age-related barriers to access and uptake of HTC and to linkages to prevention, treatment and care following testing. Young people should be able to obtain HTC without required parental or guardian consent or presence. HIV testing and counselling, with linkages to prevention, treatment and care, is recommended for adolescents from key populations in all settings (generalized, low and concentrated epidemics) (strong recommendation, very low quality of evidence). Adolescents should be counselled about the potential benefits and risks of disclosure of their HIV status and empowered and supported to determine when, how and to whom to disclose (conditional recommendation, very low quality of evidence). Children of school age should be told their HIV-positive status (strong recommendation, low quality of evidence) References