Download MBBS General Medicine PPT 10 Hiv Aids Part II Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Medicine 2022 PPT 10 Hiv Aids Part II Lecture Notes

Infectious diseases

4/5th Semester Classes on Infectious Diseases, 8-9AM, Tuesdays (LT-1)



Approach to Infectious Diseases and their prevention


Antibiotic stewardship practices


Community-Acquired Infections


Health Care?Associated Infections


Gram-Positive Bacteria (part-1)


Gram-Positive Bacteria (part-2)


Gram-Negative Bacteria (part-1)


Gram-Negative Bacteria (part-2)


Spirochetal Diseases


Diseases Caused by Atypical/Miscel aneous Bacterial Infections


Revision-cum-exam on bacteria (Must to know type)


Infections Due to DNA Viruses



Infections Due to RNA Viruses (part 1)


Infections Due to RNA Viruses (part 2)


HIV/AIDS ? part 1


HIV/AIDS ? part 2


Fungal Infections


Parasitic Infections (part 1)


Parasitic Infections (part 2)


Revision-cum-exam on Virus, Fungal, and Parasite (Must to know type)

Clinical Manifestations

The center for disease control (CDC) has classified the
clinical course of HIV infection under various groups.

1. Acute HIV infection
2. Asymptomatic or Latent infection
3. Persistent generalized lymphadenopathy (PGL)
4. AIDS related complex
5. Full blown AIDS (Last stage)

WHO clinical staging of HIV/AIDS for adults & adolescents 2010

Clinical Stage 1

Clinical stage 43


HIV wasting syndrome Pneumocystis pneumonia

Persistent generalized lumphadenopathy

Recurrent severe bacterial pneumonia

Clinical Stage 2

Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month's

Unexplained moderate weight loss (<10% of presumed or measured body weight)' Recurrent dura- tion or visceral at any site)

respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis) Herpes zoster

Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs) Extrapulmonary

Angular Cheilitis Recurrent oral ulceration Papular pruritic eruptions Seborrhoeic dermatitis tuberculosis

Fungal nail infections

Kaposi sarcoma

Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system


HIV encephalopathy

Extrapulmonary cryptococcosis including menigitis

Disseminated mycosis (extrapulmonary histoplasmosis, coccidiomycosis) Recurrent

septicaemia (including non-typhoidal salmonela)

Clinical Stage 3

Lymphoma (cerebral or B cell non Hodgkin) Invasive cervical carcinoma

Unexplained 2 servere weight loss (>10% of presumed or measured body weight)

Atypical disseminated leishmaniasis

Unexplained chronic diarrhoea for longer than one onth

Symptomatic HIV-associated nephropathy or symptomatic HIV ? associated cardiomyopathy

Unexplained persistent fever (above 37.5OC intermittent or constant for longer than one month)

Persistent oral candidiais

Oral hairy leukoplakia Pulmonary tuberculosis

Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection,

meningitis, bacteraemia)

Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis

1 Assessment of body weight in pregnant women needs to consider expected weight gain of pregnancy. 2

Unexplained anaemia (<8 g/dl), neutropenia (<0.5 x 109/litre) and or chronic

Unexplained refers to where the condition is not explained by other conditions.

thrombocytopenia (<50 x 109/litre3)

3 Some additional specific conditions can also be included in regional classifications (e.g. reactivation of

American trypanosomiasis (meningoencephalitis and / or myocarditis) in Americas region, Penicillionsis in


Acute HIV infection (window period or phase of Sero conversion)

-50?70% experience this, 3?6 weeks after primary infection
Asymptomatic or Latent infection

? Clinical latency may last from a few months to more than 10 years.

? During this period, the virus continues to multiply actively and

infects and kills the cells of the immune system.

Persistent generalized lymphadenopathy (PGL)

? This has been defined by presence of enlarged lymph nodes, at

least I cm in diameter, in two or more non contiguous extra

inguinal sites, that persist for at least three months, in the absence

of any current illness or medication that may cause


AIDS related complex / Ful blown AIDS

? A diagnosis of AIDS is made in individuals age 6 years

and older with HIV infection and a CD4+ T cell count

<200/L and in anyone with HIV infection who

develops one of the HIV-associated diseases.

? While AIDS-related illnesses are the leading cause of

death in patients with HIV infection (<50% of deaths)

Non-AIDS-defining malignancies, liver disease, and

cardiovascular disease each account for 10?15% of

Manifestations in AIDS

Treatment of HIV/AIDS as per NACO/ART Centre
Clinical Assessment

At the beginning of HIV care and prior to starting ART:

1. Determine the clinical stage of HIV infection

2. Identify history of past illnesses (especially those

related to HIV)

3. Identify current HIV-related illnesses that require


4. Determine the need for ART and OI prophylaxis

5. Identify coexisting medical conditions and

treatments that may influence the choice of therapy
Medical History

HIV Testing

HIV risks (can have multiple factors)

Pregnancy and contraception history Vaccination history

? Ever tested for HIV in the past?

? Unprotected sexual contact

? Previous pregnancies and


? Date and place of first HIV test

? Injection drug use


? Hepatitis A vaccine

? Reason for the test

? Men having sex with men

? Children and HIV status of children ? Hepatitis B vaccine

? Documentation of the result

? Occupational exposure

(living and dead)

? Date of last negative HIV test result ? Perinatal transmission

? Exposure to ARVs during pregnancy

? Previous CD4 cell counts (if available) ? Recipient of blood products

? Drugs and duration of ART

? Previous viral load (if available)

? Unknown

? Contraception used

? Partner's HIV status being positive

? Last menstrual period

System Review

Past history of HIV related ilnesses

? Unexplained weight loss

? Oral candidiasis or candida oesophagitis Medication


? Swollen lymph nodes

? Persistent diarrhoea

? Past use of drugs and reasons for

? Known allergies to drugs or other

? Night sweats and fever

? Tuberculosis

taking them

substances or materials

? Unusual headaches or poor

? Varicela zoster (Shingles)

? Current use of drugs and reasons for


? Oral hairy leukoplakia

taking them

? Changes in appetite

? Pneumocystis juroveci pneumonia (PCP) ? Current use of traditional / herbal

? Skin rashes

? Recurrent bacterial pneumonia


? Sores or white spots in mouth

? Cyptococcal meningitis

? Opioid substitution therapy (OST)

? Painful swal owing

? Toxoplasmosis

ART history

Psychosocial history

? Chest pain, cough or shortness or

? Kaposi sarcoma

? Current and past exposure to ARVs

? Family history, e.g. other immediate


? Disseminated Mycobacteriumvium

? ARV use during pregnancy of PMTCT

family members with known HIV

? Stomach pain, vomiting or diarrhea

complex Cytomegalovirus (CMV) infection ? Which drugs taken and for how long


? Numbness or tingling in hand or feet ? Invasive cervical cancer

? Social history e.g. maritial status,

? Muscular weakness and changes in

education, occupation, source of income.


Tuberculosis history

Sexualy transmit ed infections (STIs) Substance use

Functional status

? Last chest X-ray

? Genital ulcer or other lesion

? Understanding of and readiness to ? Financial and family support status

? History of past TB

? Genital discharge (abnormal vaginal

commence ART

? Disclosure status, readiness to disclose

? Treatment given (drugs and duration)

discharge in women)

? Partner's ART history (if HIV-positive) ? Availability of care and treatment

? History of exposure to TB

? Lower abdominal pain


Gynaecological history

General medical history

? Alcohol, stimulant, opiate and other ? Able to work, go to school, do

? Last PAP smear

? Any other past medical condition, such

drug use


? Menstrual irregularities

as diabetes, hypertension, coronary

? Smoking history

? Ambulatory but not able to work

? Pelvic pain or discharge

artery disease, hepatitis B, heptatis C,

? Bed ridden


? Amount of day-to-day care needed

? Mental health issues, e.g. depression

Physical examination
Record vital signs, body weight, height and body mass index (BMI), temperature,

blood pressure, pulse rate, respiratory rate
Appearance ? Unexplained moderate or severe weight loss, HIV wasting


? Look for signs suggestive of HIV infection including white plaques

? Rapid weight loss in suggestive of active Ol, especialy if associated

on tongue, cheeks and roof of mouth (oral candida), white stripped

with fever

lesions on the side of the tongue (OHL) and craking at the corners

? Gradual weight loss (not caused by malnutrition or other obvious

of the mouth (angular cheilitis)

ilness) is suggestive of HIV infection

? Difficulty in swal owing is commonly caused by oesophageal

? "Track marks" and soft tissue infections which are common among IDUs



? Malaria, tuberculosis, syphilis, gastrointestinal infections, bacterial Chest

? The most common problems will be PCP and TB


pneumonia, pelvic inflammatory disease, viral hepatitis

? Signs and symptoms are cough, shortness of breath, haemoptysis,

other than HIV

weight loss, fever, congestion or consolidation

? Perform a chest X-ray, if symptomatic


? Look for signs of HIV-related and other skin problems. These


? Hepatosplenomegaly, masses and local tenderness

include diffuse dry skin, typical lesions of PPE, especialy on the

? Jaundice may indicative viral hepatitis

legs, seborrhoetic dermatitis on face and scalp

Ano-genital ? Herpes simplex and other genital sores / lesions, vaginal or penile

? Look for herpes simplex and herpes zoster or scarring of previous


herpes zoster (especially multi-dermatome)

? Perform PAP smear, if possible

Neurologic ? Focus on visual fields and the signs of neuropathy (bilateral

Lymph nodes ? Start with posterior cervical nodes


peripheral or localized mono-neuropathies)


? Assess focal neurological deficit

PGL (persistent glandular lymphadenopathy) typical y presents as examination

multiple bilateral, soft, non-tender, mobile cervical nodes, Similar

nodes may be found in the armpits and groins

? Tuberculous lymph nodes typical y present as unilateral, painful,

hard enlarging nodes, with constitutional symptoms such as fever,

night sweats and weight loss

Note : During each consultation, patient is to be clinically screened for TB (history and physical

Laboratory Monitoring for patients at ART centres

Essential tests

Additional tests

? Haemogram/CBC,

For all patients to be started on ART (as per

? Urine for routine and microscopic

the physician's


decision depending on clinical presentation)

? fasting blood sugar,

? USG abdomen,

? blood urea,

? sputum for AFB,


? CSF analysis etc.


Ef orts to be made to fast track these

? Serum creatinine (when considering TDF) investigations so that ART initiation is not

? CD4 count,


? X-ray Chest PA view.

? Pregnancy test (if required)

PAP smear & Fundus examination also to be

? Symptoms and signs directed

done but ART initiation not to be delayed

investigations for ruling out Ols.

for these tests.

Tests for Special Situation

Tests for monitoring purpose

? HBsAg: for all patients if facility is

Essential: CD4, Hb, TLC, DLC, ALT (SGPT).

available but mandatorily for those with TDF based regimen: Creatinine/ creatinine

history of IDU, multiple blood & blood clearance, every 6 months or earlier if required.

products transfusion, ALT

AZT based regimen: Hb at 15 days, then every

> 2 times of ULN, on strong clinical

month for initial 3 months, 6 months and then

suspicion. But ART not to be withheld if every 6 months/ as & when indicated.

HBsAg testing is not available.

NVP based regimen: ALT (SGPT) at 15 days, 1

? Anti - HCV antibody: only for those with month and then every 6 months.

history of IDU, multiple blood & blood EFV based regimen: lipid profile should also be

products transfusion, ALT >2 times of

done yearly.

ULN, on strong clinical suspicion.

? For patients with Hepatitis B or C co-

ATV based regimen: LFT to be done at 15 days,

infection: further tests may be required 1 month, 3 month, 6 months and then every

to assess for chronic active hepatitis

6 months. Blood sugar and Lipid profile every 6

? For patients to be switched to a

months for patients on PI based regimen. All

PI based regimen: Blood Sugar, LFT

the above tests can be done earlier based on

and Lipid profile to be done at baseline. clinicians assessment/ discretion

Other investigations during folow up as per

requirement /availability.

Note: Al above investigations other than C04 and viral load estimations (when required), shall be done from

the health facility where the centre is located, with support from State Health Department

Goals of ARV therapy

? Clinical goals : Prolongation of life and improvement in quality of life

? Virological goals : Greatest possible reduction in viral load for as long as


? Immunological goals : Immune reconstitution that is both quantitative

and qualitative

? Therapeutic goals : Rational sequencing of drugs in a fashion that

achieves clinical, virological and immunological goals while maintaining

treatment options, limiting drug toxicity and facilitating adherence

? Reduction of HIV transmission in individuals : Reduction of HIV

transmission by suppression of viral load
When to start ART in Adults and Adolescents

WHO Clinical Stage


HIV infected Adults & Adolescents (Including pregnant women)

Clinical Stage I and I

Start ART if CD4 < 500 cells/mm3

Clinical Stage I I and IV

Start ART irrespective of CD4 count

For HIV and TB/Kalaazar co-infected patients

Patients with HIV and TB co-infection Start ART irrespective of CD4 count

(Pulmonary/ Extra-Pulmonary)

and type of tuberculosis (Start ATT

first, initiate ART as early as possible

between 2 weeks to 2 months when

TB treatment is tolerated)

For HIV and Hepatitis B and C co-infected patients

HIV and any co-infection ? without Start ART if CD4 < 500 cells/mm3

any evidence of chronic active

HIV and any co-infection ? With Start ART irrespective of CD4 count

documented evidence of chronic

active Hepatitis

Managing OIs before starting ART

Clinical Picture


Drug reaction

Do not start ART during an acute reaction

Any undiagnosed active Diagnose and treat first; start ART when stable

Acute diarrhoea which may Diagnose and treat first; start ART when diarrhoea is

infection with fever

reduce absorption ofART

stabilized or control ed


Treat TB first; start ART as recommended in TB section Non-severe anaemia (Hb < Start ART if no other causes for anaemia are found (HIV

(within 2 weeks to 2 months)

8 g/litre)



Treat PCP first; start ART when PCP treatment is

often the cause of anaemia); avoid AZT


Skin conditions such as

Start ART (ART may resolve these problems)

Treat esophageal candidiasis first; start ART as soon as

PPE and seborrhoeic

Invasive fungal diseases:

oesophageal candidiasis, the patient can swalow comfortably

dermatitis, psoriasis, HIV-

cryptococcal meningitis,

related exfoliative

Treat cryptococcal meningitis, penicil iosis,




histoplasmosis first; start ART when patient is stabilized

or OI treatment is

Suspected MAC,

Start ART (ART may resolve these problems)


cryptosporidiosis and


Bacterial pneumonia

Treat pneumonia first; start ART when treatment is

Cytomegalovirus infection Treat if drugs available; if not, start ART



Treat; start ART after 6 weeks of treatment and when


Treat malaria first; start ART when treatment is

patient is stabilized

CPT Prophylaxis

Co-trimoxazole prophylaxis recommendations

When to stop Cotrimoxazole Prophylaxis


CD4 awaited

CD4 available

When to stop prophylaxis

If CD4 count >250 for at least 6 months

primary CPT

(cotrimoxazole or Dapsone) in patients and If patient is on ART for at least 6 months,

WHO clinical stage 3 or Any WHO clinical stage and CD4 <250 on ART

is asymptomatic and wel

4 (This includes all

cells/mm3 or

patients with TB)

Any WHO clinical stage, CD4 <350

cells/mm3 and if patient is symptom- Notes:

* If CPT is started at CD4 levels between 250?350 cel s/mm3: CD4 counts should have increased, patient

atic or

is on ART for at least 6 months, is asymptomatic and well; before CPT is stopped.

WHO stage 3 or 4 irrespective of CD4


Commencing sec- For al patients who have completed successful treatment for PCP

ondary CPT

until CD4 is >200 (at least on two occasions, done 6 months apart)

Timing the initiation Start co-trimoxazole prophylaxis first.

of co-trimoxazole in Start ART about two weeks later if the patient can tolerate

relation to initiating co-trimoxazole and has no symptoms of alergy (rash,


hepatotoxicity) Meanwhile, make use of the time for adherence

and treatment preparation

Dosage of

One double-strength tablet or two single-strength tablets once


daily? total daily dose of 960 mg (800 mg SMZ + 160 mg TMP)

Cotrimoxazole for Women who fulfill the criteria for CPT should continue on it

pregnant women

throughout pregnancy.

If a woman requires CPT during pregnancy, it should be started

regardless of the stage of pregnancy

Breastfeeding women should continue CPT where indicated

Patients al ergic to Dapsone 100 mg per day, if available


Co-trimoxazole desensitization may be at empted but not in


patients with a previous severe reaction to CTX or other sulpha-

containing drugs


No specific laboratory monitoring is required in patients

receiving co-trimoxazole

ART in Adults and Adolescents

Nucleoside reverse

Non-nucleoside reverse

transcriptase inhibitors Protease inhibitors (PI)

transcriptase inhibitors (NNRTI)

Zidovudine (AZT/ZDV)* Nevirapine* (NVP)

Saquinavir* (SQV)

Stavudine (d4T)*


Ritonavir* (RTV)

Lamivudine (3TC)*

Delavirdine (DLV)

Nelfinavir* (NFV)

Didanosine (ddl)*

Fusion inhibitors (FI)

Amprenavir (APV)

Zalcitabine (ddC)*

Enfuviritide (T-20)

Indinavir* (INV)

Abacavir (ABC)*

Integrase Inhibitors

Lopinavir/Ritonavir (LPV)*

Emtricitabine (FTC)


Foseamprenavir (FPV)


CCR5 Entry Inhibitor

Atazanavir (ATV)*

Tenofavir (TDF)*


Tipranavir (TPV)

* Available in India
Revised NACO ART Regimen 2012

Regimen I

Zidovudine + First line Regimen for patients with Hb 9

Regimen I I(a)

Zidovudine +

For patients of Regimen I I who develop severe

Lamivudine + gm/dl and not on concomitant ATT


Atazanavir toxicity First line regimen for patients


+ Lopinavir /

with HIV-2 infection with Hb 9 gm/dl


Regimen IV

Tenofovir +

Second line regimen for those who are on

Regimen I (a)

Tenofovir +

First line Regimen for patients with Hb <9


AZT/d4T containing regimen in the first line.

Lamivudine +

gm/dl and not on concomitant ATT


Also for patients on TDF containing first line



regimen who develop toxicity to both NVP

and EFV

Regimen I

Zidovudine + First line Regimen for patients with Hb 9

Regimen IV (a)

Tenofovir +

For patients on Regimen IV who develop

Lamivudine + gm/dl and on concomitant ATT


severe Atazanavir toxicity First line Regimen



for patient with HIV 2 infection with Hb < 9


gm/dl First line Regimen for all women

exposed to sd-NVP in the past

Regimen I (a)

Tenofovir +

First line Regimen for patients with Hb <9 gm/dl Regimen V


Second line for those who are on TDF containing

Lamivudine +

and on concomitant ATT First line for al


regimen in the first line if Hb < 9 gm/dl


patients with Hepatitis B and/or Hepatitis C co-


infection First line Regimen for pregnant


women, with no exposure to sd-NVP in the


Regimen V(a)


For patients on Regimen V who develop


severe Atazanavir toxicity

Regimen I I

Zidovudine +

Regimen for patients on AZT Containing first



line regimen, who develop toxicity to both


+ Atazanavir/

NVP and EFV Also Second line regimen for


those who are on TDF containing first line

regimen if Hb 9 gm/dl

Choice of NRTIs





Good safety profile, non-teratogenic Once

Low genetic barrier to resistance

daily Ef ective against hepatitis B Widely

available, including In FDCs


An alternative to 3TC Good safety profile

No added advantage over 3TC except as daily

Same efficacy as 3TC against HIV and hepatitis dose Can be used as once-

B and the same resistance profile

a-day dose in combination with TDF and

EFV.(i.e. reduced pill burden and dosing



Good efficacy, safety profile Once daily

Renal dysfunction has been reported Safety in

regimens Metabolic

pregnancy not established Adverse ef ects on

complications, such as lactic acidosis and

foetal growth

lipoatrophy, are less common than with d4T and bone density reported Limited availability

at SACS on case-to-case basis


Generally wel tolerated Widely available,

Initial headache and nausea Severe anaemia

including in FDCs Metabolic complications less and neutropenia Haemoglobin monitoring

common than with d4T



Good efficacy profile Once daily Causes the Severe hypersensitivity reaction in 2-5% of

least lipodystrophy and lactic acidosis



Good efficacy profile and cheap No or limited Most associated with lactic acidosis,

laboratory monitoring Widely available in lipoatrophy and peripheral neuropathy


* Shall be available on case to case basis

* * Not supplied by NACO at present

Routine Monitoring of Patients on ART

PPTCT Services

Prong 1: Primary prevention of HIV, especially

among women of childbearing age
Prong 2: Prevention of unintended pregnancies

among women living with HIV
Prong 3: Prevention of HIV transmission from

pregnant women infected with HIV to their child
Prong 4: Provide care, support and treatment to

women living with HIV, her children and family.

What to Expect in the First Six Months

of Therapy

1. CD4 recovery
2. Early ARV toxicity
3. Mortality on ART
4. Immune reconstitution inflammatory

syndrome (In India, the agreed practical definition

of IRIS would be the "occurrence or manifestations of

new OIs or existing OIs within six weeks to six months

after initiating ART; with an increase in CD4 count")

What Toxicities to Expect after Commencing

First-line ART
Clinical, immunological and virological definitions

of treatment failure for first-line regimen (WHO,



New or recurrent WHO stage 4 condition,


after at least 6 months of ART

Immunologi ? Fall of CD4 count to pre-therapy

cal failure ? 50% fall from the on-treatment peak


? Persistent CD4 levels below 100


Virological Plasma viral load >5,000 copies/ml after


at least 6 months of ART


Recognized in 1992 characterized by:

?An absolute CD4+ T cell count of <300/l or

<20% of total T cells on a minimum of two

occasions at least 6 weeks apart;

?No evidence of HIV-1, HIV-2, HTLV-1, or HTLV-2

on testing; and

?The absence of any defined

immunodeficiency or therapy associated with

decreased levels of CD4+ T cells

Development of vaccine

Development of vaccine is fraught with several problems unique to this

virus. These include-

1) HIV can mutate rapidly, thus, it is not possible to design antibodies

against all antigens.

2) Antibody alone is not sufficient, cell mediated immunity may also be


3) Virus enters the body not as free virions but also as infected cells, in

which the virus or the provirus is protected against antibody or cell

mediated lysis.

4) Virus readily establishes life long latent infection hiding from antibodies.
Thank you

This post was last modified on 05 April 2022