HIV DISEASE
Introduction
HIV disease caused by HIV (human
immunodeficiency virus), a human retrovirus
AIDS (Acquired ImmunoDeficiency
Syndrome)is Late stage of infection with HIV
AIDS was first recognised as a clinical entity in
1981.
The first cluster of cases of Pneumocystis carinii
pneumonia and Kaposi's sarcoma with evidence
of deficiency of cell-mediated immunity (CMI)
were reported in homosexual men.
Modes of transmission
A.Sexual – Unprotected sex with infected
partner.
B.Parenteral
1.Injection : intravenous drug users (IDUs)
2.Transfusion of infected blood and blood
products
3.Transplantation
4. Infected needle-stick injuries in health-care
workers (HCWs)
C.Vertical - Infected mother to foetus
Risk of transmission
HIV structure
Types of HIV
HIV-1 can be subdivided into group M, group O and
group N (rare, highly divergent) types.
HIV-2 differs from HIV-1 in that patients have lower
viral loads, slower CD4 decline, lower rates of vertical
transmission, and slower progression to AIDS
Life cycle of HIV
aidsinfo.gov
Pathophysiology
After mucosal exposure, HIV is transported to the
lymph nodes , where infection becomes
established.
Hallmark of HIV disease is a profound
immunodeficiency.
This results from a progressive deficiency of the
subset of T lymphocytes -CD4+ T cells, (referred
to as helper or inducer T cells).
After initial transmission, the virus infects CD4+
cells, probably T lymphocytes
A small percentage of T cells enter a latent
phase and represent the main reservoir of HIV.
Within these cells there is ongoing low-level
replication even when plasma levels of HIV are
below the level of detection as a result of
antiretroviral treatment.
CD4 cells - depletion in numbers renders the
body susceptible to opportunistic infections and
oncogenic virus-related tumours.
Natural history
Primary infection
Primary infection is symptomatic in 70-80% of cases
Clinical features of this stage include Fever with rash,
Pharyngitis with cervical lymphadenopathy
Myalgia/arthralgia, aseptic meningitis
Symptomatic recovery occurs after 1-2 weeks and
parallels the return of the CD4 count and fall in the
viral load.
Diagnosis of this stage is made by detecting HIV-RNA
in the serum since appearance of specific anti-HIV
antibodies in serum (seroconversion) takes place later
at 3-12 weeks (window period)
Asymptomatic stage
Individual remains well with no evidence of
disease except for the possible presence of
persistent generalised lymphadenopathy(PGL)
At this stage the bulk of virus replication takes
place within lymphoid tissue.
This period may last upto 8-10 years.
Rate of disease progression is directly correlated
with plasma HIV RNA levels.
Symptomatic disease
This stage occurs when cellur immunity
declines.
Patients may develop various opportunistic
infections but not AIDS defining.
Common diseases that can occur in this stage
are recurrent oropharyngeal candidiasis,
recurrent vaginal candidiasis, Herpes zoster,
Chronic diarrhea, weight loss etc
Acquired immunodeficiency syndrome (AIDS)
This is last stage of HIV disease and characterised by
profound loss of immunity.
It is defined by the development of specified
opportunistic infections, tumours.
Common AIDS defining diseases are
Mycobacterium tuberculosis, any site (pulmonary
or extrapulmonary)
P. carinii pneumonia
Cryptococcosis,
Cytomegalovirus disease
Candidiasis, esophageal
Cryptosporidiosis
Kaposi’s sarcoma
Lymphoma, primary, of brain
Herpes Zoster
Active lesions Healed
Oral Candida
Diagnosis and labs - HIV disease
Laboratory diagnosis
(1) To detect HIV infection
a) Enzyme immunoassay (EIA) (enzyme-linked
immunosorbent assay) – 4th generation
Standard screening test for HIV infection
The test is highly sensitive (>99.5%).
Window period.
ELISA
b) Western blot
Most commonly used confirmatory test
Detects antibodies to HIV antigens of specific
molecular weights
c) Plasma p24 antigen levels
Increase during the first few weeks following
infection, before the appearance of anti-HIV
antibodies.
Useful test during window period
(2) Monitoring progress of HIV
infection and response to therapy
a) CD4+ T-cell count
Indicator of immunologic competence
Close relationship between the CD4+ count and
clinical manifestations of AIDS
< 200/µL: high risk of infection with Pneumocystis carinii
b) HIV RNA level
Predicts what will happen to the CD4+ T cell count in
the near future and may itself be correlated with
immune dysfunction
The quantitative PCR measures the viral load in the
peripheral blood as number of viral copies/ml of blood.
3) Investigations for Co transmitted infections
Hbs Ag- Hepatitis B
AntiHCV –Hepatitis C
Rapid plasma reagin/VDRL and TPHA - syphilis
4) Opportunistic infections and other
complications
CXR and Purified protein derivative skin test
for latent tuberculosis
Anti-Toxoplasma antibody titer – Ig Gand Ig
M
Pap smear for cervical cancer
Mini-Mental Status Examination for HIV
Encephalopathy (AIDS Dementia Complex)
5) Investigations –before starting
ART
Routine biochemistry and hematology –
CBC,FBS,RFT, LFT,FLP
Urine protein
Pregnancy testing
Summary
HIV is retrovirus
Transmission– sexual, parental, vertical
Damages immune system (esp CD4 count) and
renders body to various opportunistic infections
Natural history- 4 stages
AIDS is last stage
Diagnosis by ELISA- 4th generation
CD4 count and viral load – Disease
progression, prophylaxis and Rx response
