2 natural history of hiv and who clinical staging naco lac m

Natural History and

Clinical Staging of HIV Infection

Natural History of HIV

Session Objectives

By the end of the session the participant will be able

• To list the modes of HIV transmission

• To discuss the pathogenesis and life cycle of HIV

• To describe the progression of HIV

• To classify an HIV-infected patient according to the WHO clinical staging

Natural History of HIV 2

Semen and Vaginal Fluids

Sharing Needles

& Syringes

Through Infected Blood

During Pregnancyor Birth

Breast Feeding

Images Courtesy HIV Basics Course for Nurses, I-TECH

Needle StickInjury

Modes of HIV Transmission


Exposure Route HIV Transmission

Blood transfusion 90-95%

Perinatal 20-40%

Sexual intercourse 0.1 to 1%

Vaginal 0.05-0.1%

Anal 0.065-0.5%

Oral 0.005-0.01%

Injecting drugs use 0.67%

Needle stick exposure 0.3%

Mucous membrane splash to eye, oro-nasal

0.09%

Source: NACO PEP Guidelines

HIV Transmission Risk


How HIV Infects the Body

Exponential viral replication

Widespread systemic dissemination to the brain, spleen, distant lymph nodes, etc.

(5-11 Days)

HIV makes contact with cells located within the genital mucosa

Virus is carried to regional lymph nodes (1-2 Days)


Image Courtesy Kahn JO, Walker BD. NEJ Med.1998; 339: 33-39

Exposure to HIV atmucosal surface (sex)

Virus collected by dendritic cells, carried to lymph node

HIV replicates in CD4 cells, released into blood

Virus spreads to other organs

Day 0

Day 0-2

Day 4-11

Day 11 on

Path of the Virus


Image Courtesy HIV Basics Course for Nurses, I-TECH

HIV Lifecycle Video

HIV Lifecycle


Viral transmission

Acute retroviral syndrome: 2-3 weeks

Seroconversion: 2-4 weeks

Asymptomatic chronic HIV infection: 8 yrs (Avg.)

Symptomatic HIV infection/AIDS: 1.3 yrs (Avg.)

Stages of Untreated HIV Infection


10^6

10^2

HIV RNA Copies/ml

1 3 about 6mths // 5yrs 10 yrs

Acute HIV

Opportunisticinfections

Asymptomatic

Minor HIV-relatedsymptoms

Virologic set-point Varies from patient to

patient

HIV antibodiesAcute HIV800

200

HIV antibodies

CD4 countcells/µl

Time

Typical Course of Untreated HIV Infection

Death


• Acute Seroconversion (Acute HIV Syndrome)

• Asymptomatic HIV (Clinical latency)

• Symptomatic HIV

• Acquired Immune Deficiency Syndrome (AIDS)


Progression of HIV Disease

10

Acute HIV syndrome

• Transient symptomatic illness

• Affects 40-90% of HIV+ individuals

• Ranges from mild, non-specific illness to severe illness that can result in hospitalisation


HIV Web study (www.HIV webstudy.org) Supported by HRSA

Acute HIV syndrome: Clinical Manifestations


Courtesy: Walker, B. 40th IDSA, Chicago 2002.

Small pink macules: Trunk, limbs and faceCourtesy: Kahn, NEJM, 1998

12

Patterns of HIV Progression


• Typical progressors

• Rapid progressors

• Slow progressors

• Long-term non-progressors

WHO Clinical Staging

• WHO Clinical Staging 1

• Asymptomatic

• Persistent generalised lymphadenopathy (PGL)

• Painless enlarged lymph nodes >1 cm• In two or more non-contiguous sites (excluding

inguinal), in absence of known cause and• Persisting for 3 months


WHO Clinical Staging 2 Unexplained moderate weight loss

(<10% of presumed or measured body weight)

Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)

Herpes zoster

Angular cheilitis

Recurrent oral ulceration

Papular pruritic eruptions (PPE)

Seborrhoeic dermatitis

Fungal nail infections


WHO Clinical Staging 3 Unexplained severe weight loss

(>10% of presumed or measured body weight)

Unexplained chronic diarrhoea for longer than one month

Unexplained persistent fever (above 37.5oC intermittent or constant for longer than one month)

Persistent oral candidiasis

Oral hairy leukoplakia (OHL)

Pulmonary tuberculosis


WHO Clinical Staging 3 Severe bacterial infections (e.g. pneumonia,

empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia)

Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis

Unexplained

Anaemia (<8 g/dl)

Neutropenia (<0.5 x 109 /L) and or

Chronic thrombocytopenia (<50 X 109 /L)


WHO Clinical Staging 4 HIV wasting syndrome

Pneumocystis pneumonia (PCP)

Recurrent severe bacterial pneumonia

Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month’s duration or visceral at any site)

Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)

Extra pulmonary tuberculosis

Kaposi’s sarcoma


WHO Clinical Staging 4 Cytomegalovirus infection

(retinitis or infection of other organs)

Central nervous system toxoplasmosis

HIV encephalopathy

Extra pulmonary cryptococcosis including meningitis

Disseminated non-tuberculous mycobacteria infection

Progressive multifocal leukoencephalopathy

Chronic cryptosporidiosis

Chronic isosporiasis


WHO Clinical Staging 4 Disseminated mycosis (extra pulmonary

histoplasmosis, coccidiomycosis)

Recurrent septicaemia (including non-typhoidal salmonella)

Lymphoma (cerebral or B cell non-Hodgkin)

Invasive cervical carcinoma

Atypical disseminated leishmaniasis

Symptomatic HIV associated nephropathy or Symptomatic HIV associated cardiomyopathy


WHO Clinical Staging

Case Studies (17)


• Each trainee has to discuss one case study

• Look into the clinical photograph / X-ray

• Describe the lesion, as you observe

• Discuss Differential Diagnosis

• Identify Clinical staging of HIV infection

21

Case Study 1 and 2


Source: GHTM, Tambaram, Chennai

• Describe the lesion• Identify Clinical staging of HIV infection

22

Case Study 3


Source: GHTM, Tambaram, Chennai

23

WHO Clinical Staging in CLHIV

Image Courtesy: GHTM/ITECH Fellowship Programme, Tambaram, Chennai

Case Study 4

24

Case Study 5 & 6

Image Courtesy :GHTM, Tambaram, Chennai


OI Curriculum, GHTM-I-TECH, 2004

Images Courtesy: I-TECH-GHTM Fellowship Programme, Tambaram, Chennai


Case Study 7

Image Courtesy: Bowring Hospital, Bangalore

Case Study 8


• Describe the lesion

• What are the differential diagnosis?

• Clinical staging?

27

Image Courtesy

GHTM , Tambaram

HIV Fellowship Programme


Case Study 9

Case Study 10

Images Courtesy: GHTM/ITECH Fellowship Programme, Tambaram, Chennai

WHO Clinical Staging in CLHIV29

Case Study 11 Case Study 12

Images Courtesy: Indian Academy of Pediatrics


Image Courtesy: Indian Academy of Pediatrics

Case Study 13


Case Study 14

WHO Clinical Staging in CLHIV

Image Courtesy: GHTM/ITECH Fellowship Programme, Tambaram, Chennai

32

Case Study 15

• 5 year old child

• Respiratory distress

• Cough+

• No sputum

• Respiratory Rate: 45/mt

• Lung signs: Bilateral basal inspiratory crackles

Image courtesy: TRC, Chennai

33

• 37 year-old HIV positive male

• Lost 9 kg in last 3 months (Previously his body weight was 75 kg)

• Reports having a fever for the past month

• Treated for pulmonary TB 5 months ago

What is his WHO clinical staging?

Case Study 16


• 34 year-old HIV positive male

• Suffers from bacterial sinusitis and a fungal infection on his toes

• Has no problem keeping up with his usual activities and weight is stable

• Treated for herpes zoster 4 years ago

What is his WHO clinical staging?

Case Study 17


Key Points

• The most common mode of HIV transmission in India is sexual

• Understanding the natural history of HIV is important in predicting progress of the disease

• Clinical staging allows clinicians to reliably predict in patients:

– The risk of opportunistic infections and death

– The need for disease prevention & pre ART Care

– ART Initiation


Documents

2 natural history of hiv and who clinical staging naco lac m