HIV and AIDS

• Major cellular targets for HIV-1 are CD4 lymphocytes and macrophages.

  
• Major cellular targets for HIV-1 are CD4 lymphocytes and macrophages:

  • As CD4 count falls, increased risk of atypical/recurrent/prolonged infections
  • Increased risk of AIDS-related cancers
  • Increased risk of organ-specific HIV-related complications
  • As viral load increases, CD4 count will fall, HIV-related conditions will increase, and infectivity increases
• Routes of acquisition of HIV:

  • Sexual intercourse (sex work, any sexual encounter)
  • IV drug use
  • Mother to child transmission
  • Infected blood products
  • Occupational
• Risk reduction of HIV acquisition:

  • Sexual transmission
  • Condoms, sero-sorting, sero-positioning, regular STI screening, TasP (treatment as prevention), PREP (pre-exposure prophylaxis - giving drugs as a preventative measure to someone who is not infected)
  • IV drug use
  • Needle exchange programmes
  • Mother to child transmission
  • Ante-natal screening, TasP, birth plan, PREP for baby, avoid breast-feeding
  • Blood products
  • BBV screening
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • Respiratory
  • Tuberculosis
  • Bacterial pneumonia
  • Pneumocystis
  • Aspergillosis
  • Neurology
  • Cerebral toxoplasmosis
  • Aseptic meningitis/encephalitis
  • Primary cerebral lymphoma
  • Cerebral abscess
  • Cryptococcal meningitis
  • Peripheral neuropathy
  • Dementia
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • Dermatology
  • Kaposi's sarcoma
  • Severe or recalcitrant seborrhoeic dermatitis
  • Severe or recalcitrant psoriasis
  • Herpes zoster
  • Gastroenterology
  • Persistent cryptosporidiosis
  • Oral candidiasis
  • Oral hairy leukoplakia
  • Chronic diarrhoea
  • Weight loss
  • Salmonella
  • Shigella or campylobacter
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • Hepatitis
  • B infection
  • C infection
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • Oncology
  • Non-Hodgkin's lymphoma
  • Anal cancer or anal intraepithelial dysplasia
  • Lung cancer
  • Seminoma
  • Head and neck cancer
  • Hodgkin's lymphoma
  • Castleman's disease
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • Gynaecology
  • Cervical cancer
  • Vaginal intraepithelial neoplasia
  • Cervical intraepithelial neoplasia
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • Haematology
  • Thrombocytopenia
  • Neutropenia
  • Lymphopenia
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • Ophthalmology
  • Cytomegalovirus retinitis
  • Infective retinal diseases including herpes viruses and toxoplasma
  • Unexplained retinopathy
• Clinical indicator diseases for adult HIV infection - if a patient has any of these things, they should get a HIV test:

  • ENT
  • Lymphadenopathy of unknown cause
  • Chronic parotitis
  • Lymphoepithelial parotid cysts
  • Mononucleosis-like syndrome
  • Pyrexia of unknown origin
  • Sexually transmitted infection
• HIV treatment:

  • When to start:
  • BHIVA guidelines suggest start on diagnosis rather than CD4: <350 (START study)
  • Less AIDS-related complications
  • Reduced all cause mortality
  • Reduced transmission
  • What to start:
  • 2x NRTI + NNRTI/boosted PI/II
  • NRTI = nucleoside/nucleotide reverse transcriptase inhibitor (an antiretroviral drug)
• HAART (highly active antiretrovial therapy):

  • Aims
  • Inhibit viral replication
  • Present high genetic barrier to resistance
  • At least 3 drugs
  • At least 2 classes
  • Allow CD4 count to recover
  • Target for HAART
  • Cell entry
  • Co-receptor antagonism - CCR5
  • Fusion inhibition
  • Enzyme inhibition
  • Reverse transcriptase - NRTi/NNRTi
  • Integrase
  • Protease
• HIV in pregnancy - there's an increased risk of transmission if:

  • High viral load
  • Advanced immunodeficiency
  • Sero-conversion during pregnancy
  • STI infection
  • IVDU (intravenous drug use)/Hepatitis C
  • Malnutrition
  • Complicated labour
• Key issues in HIV care:

  • Late diagnosis
  • Stigma
  • Adherence
  • Interactions
  • Partner notification and testing
  • Prevention of transmission
  • Management of co-morbidities
  • Conception and pregnancy planning