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Clinical HIV infection

Clinical HIV infection. Gail Crowe Princess Alexandra Hospital. Objectives. Epidemiology Natural history Seroconversion Testing for HIV HIV indicator diseases Treatment. Global Estimates for Adults and Children 2007. Estimated Number of People Living With HIV Globally 1990-2007.

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Clinical HIV infection

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  1. Clinical HIV infection Gail Crowe Princess Alexandra Hospital

  2. Objectives • Epidemiology • Natural history • Seroconversion • Testing for HIV • HIV indicator diseases • Treatment

  3. Global Estimates for Adults and Children 2007

  4. Estimated Number of People Living With HIV Globally 1990-2007

  5. Estimated Number of Adult and Child Deaths Due to HIV Globally 1990-2007

  6. Adults and Children Living With HIV Globally 2007

  7. Diagnosed HIV-infected persons accessing care by prevention group1 and ethnic group2, UK 1Numbers accessing care exclude those where exposure category was not reported (1,552 in 2006) 2Ethnic group was allocated proportionally where it was not reported Annual survey of HIV-infected persons accessing care

  8. UK number of HIV diagnoses by year of diagnosis

  9. HIV in the UK: 2008 • 83,000 living with HIV • 22,400 unaware of diagnosis • 40% of HIV probably acquired in UK • 2/3 of these are in gay men • 31% of new diagnoses “late” • ie CD4 <200 • 56,556 HIV+ people accessed care • 70% on ARVs • 8% >55 yrs old

  10. HIV Attendances at PAH

  11. HIV Attendances by Risk Factor

  12. Attendances by CDC Grade

  13. Natural history Over course of infection: • CD4 count declines & HIV viral load increases • Increasing risk of developing infections and tumours • The severity of these illnesses is greater the lower the CD4 count • Most AIDS diagnoses occur at CD4 count <200

  14. Natural history Acute infection – seroconversion Asymptomatic HIV related illnesses AIDS defining illness Death

  15. Primary HIV / seroconversion • Approximately 30 - 60% of patients have a seroconversion illness. • Abrupt onset 2 – 4 weeks post exposure, self limiting 1 – 2 weeks • Symptoms generally non-specific and differential diagnosis includes range of common conditions • Serological tests for HIV antibodies may be negative or show indeterminate response

  16. Symptoms include: • Flu-like illness • Fever • Malaise and lethargy • Pharyngitis • Lymphadenopathy • Toxic exanthema • Occasionally HIV / AIDS defining illness due to profound damage to immune system (often temporary) e.g. oro-pharyngeal candida, zoster, PCP

  17. Natural history Acute infection – seroconversion Asymptomatic HIV related illnesses AIDS defining illness Death

  18. HIV associated conditions • Most of these conditions are common in the general population. • Think of HIV if presentation is: • atypical • recurrent problem • severe Suspicion may be increased if the individual is at possible risk of HIV infection

  19. Healing herpes zoster Picture from St George’s Hospital for educational use only

  20. Oral Candida Picture from St George’s Hospital for educational use only

  21. Severe oral hairy leukoplakia Picture from St George’s Hospital for educational use only

  22. Symptoms and parameters over time Opportunistic Infections Symptomatic HIV Infection

  23. Treatment for HIV • Monotherapy • Dual therapy • Triple / quadruple therapy

  24. Treatment for HIV (2) • Nucleoside / nucleotide reverse transcriptase inhibitors (Nucs) • Non nucleoside reverse transcriptase inhibitors (NNRTI) • Protease inhibitors (PI) • Fusion inhibitors • Integrase inhibitors • CCR5 inhibitors

  25. Treatment for HIV (3) • Nucs: AZT, 3TC, , Abacavir, DDI, D4T, FTC, Tenofovir • NNRTIs: Efavirenz, Nevirapine, Etravirine • PIs: Lopinavir, Atazanavir, Darunavir, Amprenavir, Saquinavir, Indinavir, Ritonavir • Fusion Inhibitors: T20 • Integrase Inhibitors: Raltegravir • CCR5 Inhibitors: Maraviroc

  26. Side Effects of Treatment • Nausea and vomiting, diarrhoea • Anaemia / pancytopaenia / abn LFTs • Insomnia • Rash • Lipodystrophy • Pancreatitis, peripheral neuropathy, lactic acidosis, renal stones

  27. Monitoring Treatment • See 3 monthly • Viral load • CD4 count • Resistance tests • Therapeutic drug monitoring

  28. BHIVA Guidelines • Launched September 2008 • Suggest HIV testing should be offered and recommended in • Gay men • Intravenous drug users • People from high prevalence areas (sub Saharan Africa) • Sexual partners of the above

  29. Gay men – London Gay men – outside London IVDU – London IVDU – not London Sub-Saharan Africa 19.1% 4.3% 3.5%(M) 5.0%(F) 0.77%(M) 0.34%(F) 5.8%(M) 8.9% (F) Risk Assessment

  30. BHIVA Guidelines • Also suggest universal testing in • GUM clinics • Antenatal services • TOP services • Drug dependency units • TB units • Patients with Hepatitis B • Patients with Hepatitis C • Patients with lymphoma

  31. BHIVA Guidelines • Also suggest universal testing in • GUM clinics ✔ • Antenatal services ✔ • TOP services ✔ • Drug dependency units ✔ • TB units ✔ • Patients with Hepatitis B ✘ • Patients with Hepatitis C ✘ • Patients with lymphoma ✘

  32. BHIVA Guidelines • Suggest that where an HIV indicator disease is present, then testing should be offered

  33. TB PCP Toxo Cerebral lymphoma Crypto meningitis PML Bacterial pneumonia Aspergillosis Aseptic meningitis Encephalitis SOL Cerebral abscess Guillain Barre Dementia Peripheral neuropathy Transverse myelitis Clinical Indicator Disease for HIV

  34. KS Cryptospoidiosis Seb dermatitis Severe psoriasis Severe shingles Oral candida OHL Persistent diarrhoea Shigella, Campylobacter, Salmonella Unexplained wt loss Hep B, Hep C Clinical Indicator Disease for HIV

  35. Kaposi’s sarcoma Picture from St George’s Hospital for educational use only

  36. KS Cryptospoidiosis Seb dermatitis Severe psoriasis Severe shingles Oral candida OHL Persistent diarrhoea Shigella, Campylobacter, Salmonella Unexplained wt loss Hep B, Hep C Clinical Indicator Disease for HIV

  37. NHL Cervical cancer Hodgkins lymphoma Lung ca Anal cancer / AIN Head and neck cancers Seminoma Castlemans disease VIN CIN 2 or above Thrombocytopenia, neutropenia, lymphopenia Clinical Indicator Disease for HIV

  38. CMV retinitis Infective retinal disease or unexplained retinopathy Unexplained lyphadenopathy Chronic parotitis “Glandular fever” PUO Any STI Clinical Indicator Disease for HIV

  39. BHIVA Guidelines on HIV Testing • Suggest that, where prevalence of HIV exceeds 2/1000 consideration should be given to testing • all medical admissions • all patients registering with a GP

  40. HIV Prevalence By PCT

  41. HIV – pre test discussion • Informed consent • Advantages and disadvantages • Risk assessment • 3 month window period • Preparing for the result • Getting the result • Health promotion

  42. Raising the subject of an HIV testCommunication strategies • Raising the subject of HIV with a patient can be difficult. • ‘The problems that you have had recently are quite common, and usually minor. However, very occasionally they can give a clue that your immune system is not working as well as it should.’ ‘I don’t know if you are at risk of HIV, but this is one condition that can affect the immune system. Could I ask you some questions to see if you could be at risk?’ .

  43. Raising the subject of an HIV testCommunication strategies • • Raise the subject of HIV before a sexual history has been taken – perhaps in a contraception or smear consultation. ‘HIV is much more common in people from Africa. Do you know people who have been affected? Would you like to consider having a test?’ • • Raise the subject of sexual health in a new patient check. ‘We find that quite a lot of young men are at risk of having sexual health problems. Could I ask you a few questions to see if you are at risk?’

  44. Raising the subject of an HIV testCommunication strategies • • Raise the subject of HIV once a sexual history has been taken. ‘Because two of your partners in the last year have been male, like you, it is possible that you are at higher risk of HIV. Have you ever considered having an HIV test?’ • • Raise the subject of HIV when a history of injecting drug use has been identified. ‘Current advice is that everyone who has injected drugs in the past should be offered a test for HIV. Have you ever considered having a test?’ • • Remember to emphasise the benefits of earlier HIV diagnosis.

  45. Risk Assement • Sexual behaviour and that of partners • Nationality, country of exposure • History of IVDU • Rape/sexual assault • Occupational exposure • Invasive procedures in unsterile conditions • Blood/blood products / organ recipient 1975-1985 (UK)

  46. Medical benefits of early HIV diagnosis • Treatments available (HAART) not cure, but prevent people becoming unwell • Prophylaxis against opportunistic infections if appropriate • Appropriate investigations if unwell • Reduce perinatal transmission • treatment for mother • delivery method • avoidance of breastfeeding (in UK)

  47. Other benefits • Minimise the risk of infecting others • Partner notification • Ability to inform important life decisions • Relief of anxiety about knowing HIV status • Access to help from social services, drug services etc

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