Human Immune Deficiency Virus Infection Huda Taha ST5

1. Human Immune Deficiency Virus Infection Huda Taha ST5 Oct. 2011

2. Epidemiology Virology Natural History Transmission Seroconversion Syndrome Diagnosis Treatment HIV in Pregnancy

3. Epidemiology The HIV pandemic continues to evolve Global Prevalence of HIV stabilise at 0.8% 25 million died of HIV 33 million living with HIV / AIDS Every day : 4,900 die of HIV/AIDS 7,100 new HIV infection 3,200 on HAART 2009 : 2.6 million new infection 2 million died of HIV/ AIDS (1.7 million <15 Year old) 4 million receive HAART in Africa( 50,000 in 2002) 1 million pregnant women on HAART WHO WHO

4. Epidemiology 100,000 people were living with a whom a quarter are unaware of their infection. 2010, there were 6,136 new diagnoses of HIV, As of December 2010, there have been 6,791 diagnoses of AIDS in the UK. 19,912 people diagnosed with HIV have died. 37 English PCT/ HIV prevalence >2:1000 1:5 HIV+ >50 Year old DOH

6. HIVis a Lentivirus a member of the Retrovirus family that causes (AIDS). HIV infects vital cells in the human immune system such as helper T cells (specifically CD4+ T cells), macrophages and dendritic cells

8. Transmission Sexual IVDU MTCT Occupational Blood transfusion

9. HIV Natural History

10. Natural history HIV vs AIDS Acquisition of Infection Primary HIV infection Asymptomatic HIV infection Early symptomatic infection Late symptomatic infection Advance HIV disease

12. Seroconversion illness“acute retroviral syndrome”

13. What is Seroconversion? Why do we need to recognise it? How does it present? What to do if you suspect HIV infection? Appropriate tests

14. Seroconversion syndrome The period between initial exposure to and infection by HIV and the development of an HIV-specific antibody response. Enormous viremia. Vigorous immune response. Rapid decline in CD4 cell count

15. Why do we need to recognise Seroconversion illness? 1 in 3 HIV + people in the UK remain undiagnosed. 80% will have symptoms of Seroconversion 60-70% will seek help Only 5% are diagnosed

16. Why do we need to recognise Seroconversion illness? To protect others: Higher risk of transmission in primary HIV infection Easier to contact trace early

17. How Does Seroconversion Illness Present?

18. Seroconversion syndrome Spectrum of Presentation completely asymptomatic infection to severe illness requiring admission to the hospital Typically, within 5 to 30 days after exposure; median duration of symptoms is 14 days.

19. How Does Seroconversion Illness Present? Non-specific, self-limiting symptoms: Fever (80-97%) Lymphadenopathy (40-77%) Rash (51-70%) Pharyngitis (44-73%) Myalgia/ arthralgia (49-70%) Headache/aseptic meningitis (30-70%) Also – mucosal ulcers, peripheral neuropathy, Bell’s Palsy, diarrhoea, nausea/vomiting

21. Bloods Thrombocytopenia Neutropenia Deranged LFTs

22. So, fever, lymphadenopathy, rash, pharyngitis– THINK HIV!

23. What would you do if you suspected HIV?Sexual history including IVDU/ travel history Get consent for an HIV testFull sexual health screen (refer to GUM)CONFIDENTIALITY

24. HIV Testing Antibody/antigen testing EIA antibody test + p24 antigen test Antibody test may still be negative up to 3/12 post-exposure. P24 antigen likely to be positive at 6 weeks If test positive or strong suspicion – refer to GUM for viral load testing.

25. What if the Test is Positive? Refer to GUM Patient will need to be seen by Health Advisors for support and advice Follow up by the HIV team for CD4 count and viral load monitoring.

26. To conclude: Seroconversion illness is a non-specific multisystem disease. Suspect in patients with fever, rash, lymphadenopathy and pharyngitis or other unusual symptoms. Early diagnosis will benefit the patient and their contacts Always refer +ve/likely +ve patients to GUM.

27. HIV treatment CART/ ARV/ ART/ HAART NRTI NNRTI PI CCR5 Inhibitor Integrase Inhibitors Fusion Inhibitors

28. When to initiate therapy Primary HIV infection: clinical trial/ neurological involvement/ or CD4 <200 cells/mL / AIDS-defining illness. Established HIV infection: CD4 <200 cells/mL Treat CD4 201–350 cells/mL Treat as soon as possible when patient ready CD4 351–500 cells/mL Treat in specific situations with higher risk of clinical events CD4 4500 cells/mL Consider enrolment into ‘when to start’ trial AIDS diagnosis Treat (except for tuberculosis)

29. Preferred regimens: 2NRTI(Tenofovir + Emtricitabine OR Abacavir +Lamivudine) PLUS NNRTI ( Efavirenz) Alternative: 2 NRTIPLUSProtease Inhibitors:Lopinavir/Ritonavir

30. HIV In Pregnancy The prevalence of HIV infection in women giving birth reached 1 in 238 (0.42%) in London, 1 in 705 (0.14%) in the rest of England. Surveillance of ( MTCT) HIV relies on confidential voluntary reports from paediatricians and obstetrics

31. Surveillance of ( MTCT) HIV relies on confidential voluntary reports from paediatricians and obstetricians. By the end of December 2010, 1,943 children in the UK had been diagnosed with HIV ( MTCT). Of these, 994 were diagnosed after having being infected abroad. The number of mother-to-child HIV infections almost doubled from 56 in 1995 to 107 in 2006. However, due to the widespread use of ARV to prevent MTCT these rates are still far lower than many other countries.

32. HIV in Pregnancy ANC Testing (100%) BHIVA guidelines Sexual Health of HIV + women. Preconception and fertility management MDT & documentation Psychosocial issues AZT monotherapy vs CART Avoid Stavudine plus Didanosine as the NRTI backbone whenever possible (and monitor lactate if unavoidable). HIV testing in children Breast feeding

33. Summery • HIV RNA virus • Transmission/ risk factors • Seroconversion illness/ could be asymptomatic • HIV testing. SUPPORT • CART • Pregnant women/ baby

34. THINK HIV Thanks Suggested site: http://www.bhiva.org