HIV " DISEASE, DIAGNOSIS AND DILEMMA"

1. H I V Disease Diagnosis Dilemma ! Presented by Dr. S. M. Aliuddin ZaheerM.B.B.S., M.D, C.I.C.(USA) Microbiologist & Infection Preventionist

2. The Disease A cquired I mmuno D eficiency S yndrome

3. HIV AIDSis the most severe manifestation of a clinical spectrum of illness caused by infection with HIV 1981 AIDS recognized due to unusual clustering of Pneumocystis jerovicii pneumonia and Kaposi’s sarcoma cases in young 1983 cytopathic retrovirus isolated 1985 serologic tests to detect evidence of infection developed and licensed HIV 1 – worldwide HIV 2 – primarily west Africa HIV genome : Family - Retroviridae Sub family - Lentivirus 2 identical molecules of ss, diploid, + ve polarity RNA 3 structural genes – gag – pol - env 6 regulatory genes – Tat, Rev, Nef, Vif, Vpr, Vpu

4. HIV Genome

5. Genes and proteins of HIV

6. HIV - Infection & dissemination

7. HIV - Infection & dissemination

8. Cytokine networks that regulate HIV replication

9. HIV – Replication cycle

10. Surveillance case definition for HIV infection among Adults and Adolescents – US 2008

11. AIDS Defining Conditions

12. Angular chelitis Apthous stomatitis Herpes simplex Oral candidiasis

13. Herpes zoster - dermatomal Molluscum contagiosum Crptococcosis Histoplasmosis

14. Eosinophillic dermatitis Sebhorric dermatitis Norwegian scabies Kaposi’s sarcoma

15. Natural history of HIV infection

16. DIAGNOSIS A cquired I mmuno D eficiency S yndrome

17. Testing Techniques

18. HIV testing categories

19. HIV testing categories

20. Diagnostic devices “Oraquick” Rapid Automated ELISA processor Multiplex PCR used for NAT screening

21. Window Period It is the time after the infection has occurred but before the evidence of HIV infection is detectable. HIV diagnostic window represents a vulnerable period from the standpoint of blood safety. Reducing from 2.1 months to 6 weeks to 22 days to 16 days to around 12 days only for the NAT. And reducing further …………

22. ELISA Test Principle

23. The END ELISA Test types First generation - used infected viral cell lysate as antigen Second generation - used glycopeptides recombinant antigensThird generation - synthetic peptides are used as antigens.Fourth generation - are the newer tests for simultaneous detection of p24 Ag (HIV-1 Ag) and HIV-1/HIV-2Ab.

24. Results of HIV Ag/Ab Combo assay, HIV Ab (gO) assay, and p24 antigen assay performed during HIV seroconversion. Speers D et al. J. Clin. Microbiol. 2005;43:5397-5399

25. Western Blot

26. Screening Algorithm

27. Confirmation Algorithm

29. World “AIDS day” theme

30. HIV Case Notification rates in the Kingdom over the Past Decade (2000-2009)

31. Mother to child transmission of HIV : experience at a referral hospital in Saudi Arabia

34. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings For patients in all health-care settings • HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening) • Persons at high risk for HIV infection should be screened for HIV at least annually. • Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. • Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. For pregnant women • HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. • HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening) • Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. • Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.

36. Dilemma 1) Indeterminate Western blot results 2) Minimally reactive confirmatory test results from noninfected individuals 3) Inconsistent results when repeating specimens or testing follow-up specimens 4) The occurrence of technical errors 5) False-negative results due to HIV Group O viruses and 6) Laboratory diagnosis of HIV infection in the newborn

37. Special Circumstances • Screening in pregnancy • Perinatal diagnosis • HIV testing of blood donors • HIV testing and vaccine studies • Occupational exposure • Factitious HIV testing

38. Post-Test Counselling Provide the patient with his/her HIV test result Help understand what the result means Provide support, information, and referral when indicated Encourage risk- reducing behavior Encourage disclosure and partner testing

39. Post-Test Counselling HIV-positive result Clarify understanding Acknowledge feelings Review benefits of knowing HIV status Address immediate concerns Schedule follow-up visit Provide support ,name and telephone number of contact person

40. Post-Test Counselling HIV-negative Review window period if indicated Prevent future infection Review risk with new infection Educate partner and encourage partner testing

41. Disclosure Ensure confidentiality Respect choices Encourage partner testing Review prevention of transmission Identify support

42. HIV – Replication cycle

43. Anti-HIV medications

44. Thanks… ..for the patient listening, “Lets help!”