HIV AND AIDS PREVENTION

1. HIV AND AIDS PREVENTION DR. DOREEN ASIMBA CHS, 28.02.2015

2. Historical Background • 1981 – CDC(USA): Unexplained PCP/KS in previously healthy homosexual men • 1984 – HIV virus clearly demonstrated to be the causative agent • 1984 – First case of AIDS was described in Kenya • 1986 - Human Immunodeficiency Virus (HIV) accepted as international designation for the retrovirus in a WHO consultative meeting

3. Modes of Transmission • Sexual contact most important mode of transmission/acquisition of HIV worldwide • Heterosexual • Homosexual • Non-consensual sexual exposure (assault) • Parenteral • Blood or blood products • Infected blood or body fluids through contaminated sharps • IDU through needle-sharing or needle stick accidents • Donated organs • Traditional procedures • Perinatal • Transplacental, during labor/delivery and breastfeeding • HIV is not transmitted by casual contact, surface contact, or from insect bites

4. Percent infection by transmission route….

5. Biological Factors Influencing HIV Transmission • Disease status of source person • Degree of imunosuppression (primary infection , VL ,CD4) • Presence of untreated STIs in source & person at risk • High VL in genital secretions in STIs/disturbance of genital mucosa A major reason for high prevalence in SSA • Circumcision status • Uncircumcised men 2x as likely to acquire HIV infection than circumcised. Also more likely to acquire STIs • Gender differences in susceptibility • Female genital anatomy presents a larger surface area • (Socio-cultural factors) • Genetic host differences

6. Socio-economicFactors Facilitating HIV Transmission • Social Mobility • Global Economy • HIV/AIDS follows routes of commerce • Partners living apart • Stigma and Denial • Denial and silence is the norm • Stigma prevents acknowledgment of problem and care-seeking • People in Conflict • Context of war and struggle of power spreads AIDS • Cultural Factors • Traditions, beliefs, and practices affect understanding of health and disease and acceptance of conventional medical treatment

7. Socio-economicFactors (cont’d) • Gender • In many cultures it is accepted for men to have many sexual relationships • Women suffer gender inequalities • Many women unable to negotiate condom use • Poverty • Lack of information needed to understand and prevent HIV • Drug Use and Alcohol Consumption • Impaired judgment • Sharing of needles and equipment

8. Behavioral Factors • Multiple sexual partners • Unprotected sexual intercourse • Large age difference between sexual partners

9. Natural History and Progression Of HIV Infection

10. HIV AND AIDS • The hallmark of HIV and AIDS is a profound immunodeficiency as a result depletion of CD4+ T lymphocytes. • The CD4+ T cell depletion is two fold • Reduction in numbers • Impairment in function

11. 800 10,000,000 1,000,000 500 100,000 Non-progressors:normal CD4 count, low detectable viral load; no need to treat 10,000 200 1,000 100 100 50 Months Years 10 0 CD4 Count (cells/mL) HIV in plasma (copies/mL) HIV in plasma (“viral load”) CD4 (T Cell) count

12. Natural History of HIV Infection • Rapid Progressors 5– 10%, AIDS 1-2 years • Intermediate Progressors 80-90%, Asymptomatic 5-8 years • Slow Progressors 5-10%,Good immune responses 10-15 years, Rare

13. Symptomatic Disease and AIDS • Viral load continues to rise causing • Increased demands on immune system as production of CD4 cells cannot match destruction • Increased susceptibility to common infections (URTI, pneumonia, skin etc) • Late-stage disease is characterized by a CD4 count <200 cells/mm3 and the development of opportunistic infections, selected tumors, wasting, and neurological complications).

14. Tuberculosis Bacterial infections Pneumonia Gram negative sepsis Pneumocystis pneumonia -PCP (now Pneumocystis jiroveci previously carinii) Cryptococcal meningitis Toxoplasmosis Candidiasis Infective diarrhoea Herpes Zoster Infective Dermatoses Common Opportunistic Infections

15. Opportunistic Infections • The infections are an indication of how advance the HIV disease is  • Hence an indication of when to start ARVs  • A major cause of stigmatization • Prevention of OIs with ARVs

16. Important Messages about OIs • Opportunistic infections cause the vast majority of the morbidity and mortality associated with HIV • Most are readily treatable and/or preventable • Most of these treatments are simple, available and affordable

17. TB and HIV • TB is the major opportunistic infection in Kenya • Since the onset of the HIV epidemic in the early eighties in Kenya, the prevalence of TB stopped falling and over the past 2 decades has risen sharply • HIV fuels the TB epidemic • HIV is the single most important risk factor for TB • >50% TB patients are HIV co-infected

19. TB and HIV • TB occurs by • reactivation of latent infection • newly acquired infection • HIV increases the risk of TB progression • HIV increases the rate of TB progression • TB may speed the progression of HIV disease • ART reduces the incidence of TB in PLHA

20. TB/HIV: Conclusion • TB a major cause of morbidity and mortality in HIV patients • TB occurs at any stage of HIV infection • EPTB/atypical presentations of TB more common in severe HIV disease • All co-infected patients should be started on cotrimoxazole prophylaxis as it reduces mortality • HIV patients on ART remain at risk of developing TB; active case detection important

21. TB Preventive Strategies • Routine neonatal BCG in all children except for those with AIDS/severe immunosuppression • Effective case finding and treatment of infected and infectious people • Treatment of latent tuberculosis infection (LTBI) = INH prophylaxis • Reduces the risk of • progression of recently acquired TB • reactivation of latent TB infection • Particularly in individuals with a positive Mantoux test • Benefits last up to 2.5 years

22. ART is recommended for prevention: • “ART also is recommended for HIV-infected individuals for the prevention of transmission of HIV.” • HIV viral load directly related to probability of HIV transmission; increased ART use and lower community viral load associated with lower HIV incidence www.aidsetc.org

23. Post-Exposure Prophylaxis (PEP) ARV prophylaxis is recommended for occupational and non-occupational high risk exposure.

24. Risk assessment after exposure to body fluids Risk assessment after exposure to body fluids

25. Summary of medical management of medical PEP

26. PRE-EXPOSURE PROPHYLAXIS (PrEP)

27. Pre-Exposure Prophylaxis (PrEP)

28. GOALS OF PrEP THERAPY • To reduce the acquisition of HIV infection with its resulting morbidity, mortality, and cost to individuals and society • MSM, heterosexually active men and women, and IDU who meet recommended criteria

29. STRATEGIES FOR PREVENTION OF HIV INFECTION: HIV NEGATIVE • Know your HIV status : HCT (testing & counseling) • BEHAVIOUR CHANGE & RISK REDUCTION : ABC, • PMTCT: -ve children • VMMC • POST EXPOSURE PROPHYLAXIS • PRE EXPOSURE PROPHYLAXIS • CULTURAL PRACTICES (FGM, wife inheritance) • EDUCATION/INFO (TBA, Public) • EMPOWER THE GIRL CHILD (education) • Commandment: DO NOT COMMIT ADULTERY

30. STRATEGIES FOR PREVENTION OF HIV TRANSMISSION : HIV POSITIVE • Behaviour change (consistent condom usage, safer sexual and drug-use practices) • Early diagnosis : HCT (testing & counseling) • Antiretroviral treatment(prevents OIs, ↓incidence of Tb, ↓ risk sexual transmission) • Detection and treatment of STIs • Early diagnosis & treatment of OIs • Stigma reduction

31. SUMMARY: PREVENTION STRATEGIES • BEHAVIOUR CHANGE & RISK REDUCTION • ANTIRETROVIRAL THERAPY • HCT: Early diagnosis, Early Rx • POST EXPOSURE PROPHYLAXIS • PMTCT • VMMC

32. THANK YOU