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)
Topics
1
Approach to Infectious Diseases and their prevention
2
Antibiotic stewardship practices
3
Community-Acquired Infections
4
Health Care?Associated Infections
5
Gram-Positive Bacteria (part-1)
6
Gram-Positive Bacteria (part-2)
7
Gram-Negative Bacteria (part-1)
8
Gram-Negative Bacteria (part-2)
9
Spirochetal Diseases
10
Diseases Caused by Atypical/Miscel aneous Bacterial Infections
11
Revision-cum-exam on bacteria (Must to know type)
12
Infections Due to DNA Viruses
1
13
Infections Due to RNA Viruses (part 1)
14
Infections Due to RNA Viruses (part 2)
15
HIV/AIDS ? part 1
16
HIV/AIDS ? part 2
17
Fungal Infections
18
Parasitic Infections (part 1)
19
Parasitic Infections (part 2)
20
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
Asymptomatic
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
toxoplasmosis
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
Aisa)
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
lymphadenopathy.
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
deaths
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
treatment
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
? BCG
? Date and place of first HIV test
? Injection drug use
terminations
? 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
Alergies
? 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
concentration
? Oral hairy leukoplakia
taking them
? Changes in appetite
? Pneumocystis juroveci pneumonia (PCP) ? Current use of traditional / herbal
? Skin rashes
? Recurrent bacterial pneumonia
remedies
? 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
breath
? 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
infection
? 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.
vision
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
supporter
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
housework
? 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
hyperlipidaemia
? 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
Mouth
? 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
candida
Consider
? Malaria, tuberculosis, syphilis, gastrointestinal infections, bacterial Chest
? The most common problems will be PCP and TB
conditions
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
Skin
? Look for signs of HIV-related and other skin problems. These
Abdomen
? 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
discharge
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
al
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
examination)
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
examination,
decision depending on clinical presentation)
? fasting blood sugar,
? USG abdomen,
? blood urea,
? sputum for AFB,
? ALT (SGPT),
? CSF analysis etc.
? VDRL,
Ef orts to be made to fast track these
? Serum creatinine (when considering TDF) investigations so that ART initiation is not
? CD4 count,
delayed.
? 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
possible
? 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
Recommendations
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
Hepatitis
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
Action
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
TB
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)
is
PCP
Treat PCP first; start ART when PCP treatment is
often the cause of anaemia); avoid AZT
completed
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,
peniciliosis,
dermatitis
histoplasmosis
histoplasmosis first; start ART when patient is stabilized
or OI treatment is
Suspected MAC,
Start ART (ART may resolve these problems)
completed
cryptosporidiosis and
microsporidiosis
Bacterial pneumonia
Treat pneumonia first; start ART when treatment is
Cytomegalovirus infection Treat if drugs available; if not, start ART
completed
Toxoplasmosis
Treat; start ART after 6 weeks of treatment and when
Malaria
Treat malaria first; start ART when treatment is
patient is stabilized
completed
CPT Prophylaxis
Co-trimoxazole prophylaxis recommendations
When to stop Cotrimoxazole Prophylaxis
Commencing
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
count
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,
ART
hepatotoxicity) Meanwhile, make use of the time for adherence
and treatment preparation
Dosage of
One double-strength tablet or two single-strength tablets once
cotrimoxazole
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
sulpha-based
Co-trimoxazole desensitization may be at empted but not in
medications
patients with a previous severe reaction to CTX or other sulpha-
containing drugs
Monitoring
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)
(NRTI)
Zidovudine (AZT/ZDV)* Nevirapine* (NVP)
Saquinavir* (SQV)
Stavudine (d4T)*
Efavirenz*(EFV)
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)
Raltegravir
Foseamprenavir (FPV)
(NtRTI)
CCR5 Entry Inhibitor
Atazanavir (ATV)*
Tenofavir (TDF)*
Maraviroc
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
Lamivudine
Atazanavir toxicity First line regimen for patients
Nevirapine
+ Lopinavir /
with HIV-2 infection with Hb 9 gm/dl
Ritonavir
Regimen IV
Tenofovir +
Second line regimen for those who are on
Regimen I (a)
Tenofovir +
First line Regimen for patients with Hb <9
Lamivudine+
AZT/d4T containing regimen in the first line.
Lamivudine +
gm/dl and not on concomitant ATT
Atazanavir/
Also for patients on TDF containing first line
Nevirapine
Ritonavir
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
Lamivudine+
severe Atazanavir toxicity First line Regimen
Efavirenz
Lopinavir/
for patient with HIV 2 infection with Hb < 9
Ritonavir
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
Stavudine+
Second line for those who are on TDF containing
Lamivudine +
and on concomitant ATT First line for al
Lamivudine+
regimen in the first line if Hb < 9 gm/dl
Efavirenz
patients with Hepatitis B and/or Hepatitis C co-
Atazanavir/
infection First line Regimen for pregnant
Ritonavir
women, with no exposure to sd-NVP in the
past
Regimen V(a)
Stavudine+
For patients on Regimen V who develop
Lamivudine+
severe Atazanavir toxicity
Regimen I I
Zidovudine +
Regimen for patients on AZT Containing first
Lopinavir/
Lamivudine
line regimen, who develop toxicity to both
Ritonavir
+ Atazanavir/
NVP and EFV Also Second line regimen for
Ritonavir
those who are on TDF containing first line
regimen if Hb 9 gm/dl
Choice of NRTIs
NRTI
Advantages
Disadvantages
3TC
Good safety profile, non-teratogenic Once
Low genetic barrier to resistance
daily Ef ective against hepatitis B Widely
available, including In FDCs
FTC**
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
schedule)
TDF*
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
AZT
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
recommended
ABC**
Good efficacy profile Once daily Causes the Severe hypersensitivity reaction in 2-5% of
least lipodystrophy and lactic acidosis
adults
D4T
Good efficacy profile and cheap No or limited Most associated with lactic acidosis,
laboratory monitoring Widely available in lipoatrophy and peripheral neuropathy
FDCs
* 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,
2010)
Clinical
New or recurrent WHO stage 4 condition,
failure
after at least 6 months of ART
Immunologi ? Fall of CD4 count to pre-therapy
cal failure ? 50% fall from the on-treatment peak
value
? Persistent CD4 levels below 100
cells/mm
Virological Plasma viral load >5,000 copies/ml after
Failure
at least 6 months of ART
IDIOPATHIC CD4+ T LYMPHOCYTOPENIA
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
necessary.
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