This Could Happen to YOU!

1. This Could Happen to YOU! Robert R. Tight, MD FACP Bradley Kasson, DDS Roger Schobinger Dakota AIDS Education and Training Center

2. What is HIV? • Human: Infecting human beings • Immunodeficiency: Decrease or weakness in the body’s ability to fight off infections and illnesses • Virus: A pathogen having the ability to replicate only inside a living cell

3. Types of HIV Virus • HIV 1 • Most common in sub-Saharan Africa and throughout the world • Groups M, N, and O • Pandemic dominated by Group M • Group M comprised of subtypes A - J • HIV 2 • Most often found in West Central Africa, parts of Europe and India

4. What is AIDS? • Acquired: To come into possession of something new • Immune Deficiency: Decrease or weakness in the body’s ability to fight off infections and illnesses • Syndrome: A group of signs and symptoms that occur together and characterize a particular abnormality AIDS is the final stage of the disease caused by infection with a type of virus called HIV.

5. HIV vs. AIDS • HIV is the virus that causes AIDS • Not everyone who is infected with HIV has AIDS • Everyone with AIDS is infected with HIV • AIDS is result of the progression of HIV Infection • Anyone infected with HIV, although healthy, can still transmit the virus to another person

6. How is HIV Transmitted? • Unprotected sexual contact with an infected partner • Exposure of broken skin or wound to infected blood or body fluids • Transfusion with HIV-infected blood • Injection with contaminated objects • Mother to child during pregnancy, birth or breastfeeding

7. Basic Terms • Antigen: A substance which is recognized as foreign by the immune system. Antigens can be part of an organism or virus, e.g., envelope, core (p24) and triggers antibody production. • Antibody: A protein (immunoglobulin) made by the body’s immune system to recognize and attack foreign substances

8. Testing for Viral Infection and Immune Response • Viral infection • Viral Load • p24 Antigen • Immune response • Antibody (IgG, IgM) • Cellular response (CD4)

9. Window Period • Time from initial infection with HIV until antibodies are detected by a single test • Usually 3-8 weeks before antibodies are detected • May test false-negative for HIV antibodies during this time period • Can still pass the virus to others during this period

10. Disease Progression • Severity of illness is determined by amount of virus in the body (increasing viral load) and the degree of immune suppression (decreasing CD4+ counts) • As the CD4 count declines, the immune function decreases.

11. WHO HIV/AIDS Classification System Stage I Asymptomatic Stage II Minor Symptoms Stage III Moderate Symptoms Stage IV AIDS

12. YES Can Disease Progression Be Delayed? • Prevention and early treatment of opportunistic infections (OIs) • Antiretroviral therapy • Positive living

13. HCW HIV PEP Risk Stratification • Highest risk: larger volume of blood (e.g., deep injury, large diameter hollow needle) and blood containing high titer of HIV (e.g., source patient with acute retroviral illness or end-stage AIDS) • No increased risk (e.g., solid suture needle from asymptomatic source patient) • No known risk (e.g., urine, saliva, tears) • Source patient unknown or HIV status unknown: decide on case-by-case basis, in consultation

14. HCW HIV PEP • Basic (2 drug) regimen • Combivir® (ZDV/3TC) 1 tab bid or • Truvada® (TDF/FTC) 1 tab daily • Expanded regimen: Kaletra® (LPV/r)2 tabs bid • Initiate promptly: 1-2hr/<72hr/?longer • Duration: 4 wks BUAD:initial(3d), then 2 wksx2 • initial supply packet • 2 wks supply at a time • start on basis of preliminary + • stop if confirmatory test is negative • 24 hours PEP line: 1-888-448-4911

15. Exposure to HIV at mucosal surface (sex) Day 0 Virus collected by dendritic cells, carried to lymph node Day 0-2 HIV replicates in CD4 cells, released into blood Day 4-11 Day 11 on Virus spreads to other organs Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39.

16. HCW HIV PEP Monitoring • Anti-HIV: baseline, 6 and 12 wks, 6 (and 12 mo. if source + HCV/HIV) • CBC, basic panel; UA: baseline, 2, 4 wks • Baseline pregnancy test

17. This Could Happen to YOU! Robert R. Tight, MD FACP Bradley Kasson, DDS Roger Schobinger Dakota AIDS Education and Training Center Robert.tight@meritcare.com

18. Oral Manifestations of HIV Dakota AIDS Education and Training Center Bradley M Kasson, DDS Consultant for Infection Control Office of Dentistry, Washington DC Chief, Dental Service VA Medical Center, Fargo

19. Oral Manifestations of HIV No identified unique oral lesion specific to HIV Seldom manifest with CD4 >400 Some predict progression to AIDS Some meet criteria for AIDS diagnosis Casiglia JM, Mirowski GW, Oral Manifestations of Systemic Diseases. eMedicine. Oct 2006

20. Predictive Value CD4+ < 200 Major Aphthous Stomatitis 100% NUP 95.1% Intraoral Kaposi’s Sarcoma 93.6% HSV (long standing) 87.0% Oral Hairy Leukoplakia 70.3% Oral Candidiasis 69.9% Dental Management of the HIV-Infected Patient Supplement to JADA , December 1995

21. Candidiasis 90% of HIV patients* • Pseudomembranous • Erythematous • Angular Cheilitis • Hyperplastic *Casiglia JM, Mirowski GW, Oral Manifestations of Systemic Diseases. eMedicine. Oct 2006

22. Angular Cheilitis (Candida)

23. Pseudomembranous Candidiasis

24. Pseudomembranous Candidiasis

25. Pseudomembranous Candidiasis

26. Pseudomembranous Candidiasis: Wikipedia

27. Erythematous Candidiasis 33yo

29. Erythematous Candidiasis

30. Hyperplastic Candidiasis

31. HIV Oral Candidiasis Treatment • Nystatin not first choice • Increasing resistance to azoles • Fluconazole • Itraconazole • Ketaconazole • Clinical recovery precedes mycologic elimination • Treat the removable denture • Clean & disinfect daily Casiglia JM, Mirowski GW, Oral Manifestations of Systemic Diseases. eMedicine. Oct 2006

32. Necrotizing Ulcerative Periodontitis

33. Necrotizing Ulcerative Periodontitis

34. Necrotizing Ulcerative Gingivitis

35. Necrotizing Ulcerative Gingivitis post chlorhexidine therapy

36. NUG/NUP Treatment • Debridement, usually with local anesthesia • Oral hygiene instruction • Chlorhexidine gluconate • Apply with toothbrush, if possible • Follow-up cleaning • Oral hygiene instruction • Regular dental cleanings • Oral hygiene instruction

37. Oral Hairy Leukoplakia (OHL) Cardiac Transplant

38. Oral Hairy Leukoplakia (OHL) 33yo

39. Oral Hairy Leukoplakia (OHL) 21 yo

40. OHL • Most specific oral manifestation of HIV* • Usually no treatment indicated • Usually responds to acyclovir • High recurrence rate • If symptomatic, usually indicates Candida superinfection* *Casiglia JM, Mirowski GW, Oral Manifestations of Systemic Diseases. eMedicine. Oct 2006

41. Aphthous Stomatitis

42. RAS Treatment Recommendations, Barron • Topical is tx of 1st choice • Amlexanox (Aphthasol) most extensively studied and most cost effective of topicals • Inhibits inflammatory mediators • Levamisole • “…may prove to be the safest & most effective systemic agent for maintaining remission…” • Normalize CD4/CD8 ratio • Systemic corticosteroids • Major RAS or esophageal/GI involvement • Thalidomide • Limited to patients with severe RAS as alternative to systemic corticosteroids for esophageal/GI involvement • Significant adverse effects • Normalize CD4/CD8 ratio, inhibit cytokines & TNF Barron RW. Treatment strategies for recurrent oral aphthous ulcers. Am J Health-Syst Phar 58(1):41-52,2001