lecture 61

1. Up To date in the Prevention and
Management of
H IV Infection
By
Dr . Magdy Shafik Ramadan
Senior Pediatric and Neonatology consultant
M.S, Diploma, Ph.D of Pediatrics

2. Topics
• Epidemiology – World, US • History
• Transmission & Opportunistic
infections
• Testing
• Prevention
• Treatment
• Co-morbidities / HIV related Topics

3. What is HIV/AIDS?
HIV means Human immunodeficiency
virus
while AIDS means Acquired
Immunodeficiency Syndrome
–It’s a disease of the human immune
system caused by the human
immunodeficiency virus (HIV).

4. HISTORY
• 1981……First Reported Case of AIDS
• 1982……..First Use of “AIDS” Acronym
• 1984……..Causative Agent Identified
• 1985…….First HIV Antibody Test
• 1986……First Use of “HIV” Acronym
• 1987……First Medication

5. What is HIV?
• HIV is a virus that compromises the immune
system.
• The virus invades the T-cell and multiplies
once it gets inside of it.
• The newly manufactured virus buds from the
Tcell, eventually destroying the host cell.
• This process, unchecked, continually repeats
until there are a low number of T-cells and high
viral load.

6. • Once an individual is infected with
HIV, the virus is never dormant in
their system.
• Human Immunodeficiency Virus is a lot like
other Viruses, but the difference is that,
your immune system can clear most viruses
out of your body. But can not get rid of
HIV. Scientists are still trying to figure out
why

7. Where did it come from?
• Scientists identified a type of chimpanzee in
West Africa as the source of HIV infection in
humans.
The virus most likely jumped to humans when
humans hunted these chimpanzees for meat and
came into contact with their infected blood.
Over several years, the virus slowly spread across
Africa and later into other parts of the world.

8. HIV/AIDS in Egypt
• Egypt is a low-HIV-prevalence country.
• Between the years 2006 and 2011, HIV
prevalence rates in Egypt increased
tenfold Until 2011, the average number of
new cases of HIV in Egypt was 400 per year.
• But, in 2012 and 2013 it increased to about
600 new cases.

9. • And in 2014 it reached 880 new cases per
year
• According to UNAIDS 2016 statistics, there
are about 11,000 people currently living
with HIV in Egypt.
• However, unsafe behaviors among most-at-
risk populations and limited condom usage
among the general population place Egypt
at risk of a a broader epidemic.

10. HIV Life Cycle
• 1. HIV binds to the T-cell
• 2. Viral RNA is released into the host cell
• 3. Reverse transcriptase converts viral RNA into
viral DNA.
• 4. Viral DNA enters the T-cells nucleus and inserts
itself into the T-cell’s DNA.
• 5. The T-cell begins to make copies of the HIV
components.
• 6. Protease helps create new virus particles.
• 7. The new HIV virion is released from the T-cell.

11. • Virus enters and attacks cells
• Host immune system attempts to respond
• Acute retroviral syndrome
• Sudden drop in CD4
• High viremia
• Flu-like symptoms
– Antibody response

12. • the amount of time that it takes an
individual to seroconvert as the
window period.
• Symptoms of acute HIV infection
generally occur 2 to 6 wks

13. •Transmission

14. • Most commonly unprotected sex with
an infected person.
• Blood-to-Blood contact mostly by
sharing injection needles
• Infected woman to her newborn child
• Breast feeding

15. • An HIV infected mother can infect
her child:
• In-utero (in the womb)
• During birth
• During breastfeeding

16. Which Body Fluids Contain HIV?
• The following fluids can contain high levels
of HIV:
• • Blood
• • Semen (cum)
• • Pre-seminal fluid (pre-cum)
• • Breast milk
• • Vaginal fluids
• • Rectal (anal) mucous

17. • Other body fluids and waste products—like
feces, nasal fluid, saliva, sweat, tears, urine,
or vomit—don’t contain enough HIV to
infect you, unless they have blood mixed in
them and you have significant and direct
contact with them.
• Healthcare workers may be exposed to some
other body fluids with high concentrations
of HIV, including:
• • Amniotic fluid
• • Cerebrospinal fluid
• • Synovial fluid

18. HIV is a very fragile virus
• Hot water, soap, bleach and alcohol will kill
the virus
• • The length of time the virus can survive
outside the body depends on the amount of
HIV present in the fluid
• • The CDC reports drying HIV reduces the
viral load

19. • Point of Entry
• – Percutaneously
• • Puncture/needle
• • Break in the skin
• –Mucous membrane
• • Eyes
• • Nose
• • Mouth
• • Genitals
• • Anus

20. • The most efficient way to transmit
the HIV virus sexually is through anal sex.
• The next most efficient route is vaginally.
• While the risk is not as high as anal or vaginal
sex it has been found that there is significant
risk associated with oral sex.

21. Ways through which HIV/AIDS is not
contacted
HIV is not spread by:
• • Air or drinking water from the same
pot with an infected person.
• • Insects: including mosquitoes. •
Saliva, tears, or sweat. There is no
documented case of HIV being
transmitted by spitting.
• • shaking hands or sharing dishes.
• • Closed-mouth or ―social‖ kissing.

23. HIV Infection/AIDS Staging System
• Stage 1: Asymptomatic; persistent
generalized lymphodenopathy (PGL)
and acute retroviral infection (ARI).
• Stage 2: Loss of weight (< 10% of body
weight); minor mucocutaneous
infections; herpes zoster and recurrent
upper respiratory tract infections
(URTI).

24. • Stage 3: Loss of weight (>10% of body
weight); chronic diarrhea(> 1 month);
prolonged fever; oral candidiasis; oral
hairy leukoplakia; pulmonary
tuberculosis; severe bacterial infections
and vulvovaginal candidiasis.

25. • Stage 4: HIV wasting syndrome;
extrapulmonary tuberculosis;
Pneumocystis carinii pneumoniae,
Candidiasis of the oesophagus, trachea,
bronchi or lungs; toxoplasmosis of the
brain, cryptosporidiasis with
mycobacteriosis; lymphoma; Kaposi’s
sacoma (KS) and HIV encephalopathy.

26. HIV – Testing
• Antibody Tests
– Elisa/EIA
– Western Blot
• Tests for the Virus
– Qualitative PCR
– Quantitative PCR
• Tests to Monitor Therapy
– CD4—absolute and percent
– Quantitative PCR – Genotype

27. Prevention

28. 1- Vertical transmission
2- Blood-borne transmission
3-Postexposure prophylaxis
4- Pre exposure prophylaxis
5-Vaccination efforts
6- Condoms, Male and Female
7-Voluntary Medical Male Circumcision

29. Vertical transmission
Prevention measures include the following:
1-Maternal testing
2-Effective control of maternal infection
3-Prenatal antiviral therapy and treatment
of mother and infant during labor,
delivery, and the neonatal period
4-Cesarean delivery
5-Avoidance of breastfeeding (unless local
conditions make this unsafe or unfeasible)

30. • A retrospective cohort study reviewed the
records of 3,273 HIV-positive women
receiving prenatal care in Malawi and
Mozambique from July 2005 to December
2009. Patients were treated with triple
antiviral therapy during pregnancy until 6
months postpartum for prevention of vertical
transmission. Regardless of CD4 count,
ART provided a protective effect against
mortality, fetal demise, and premature
birth

31. Blood-borne transmission
Prevention measures include the
following:
• Blood-product and donor screening
• Avoidance of reusing needles for
intravenous drug abuse

32. Postexposure prophylaxis
The CDC has recommended basic and
expanded HIV postexposure prophylaxis (PEP)
regimens
• Basic PEP 2-drug regimen: zidovudine plus
lamivudine, zidovudine plus emtricitabine,
tenofovir plus lamivudine, or tenofovir plus
emtricitabine
• Expanded PEP regimen: basic PEP regimen
plus lopinavir-ritonavir

33. Preexposure prophylaxis
• According to these guidelines, PrEP should
be considered for the following non-HIV-
infected individuals:
•
• Anyone who is in an ongoing sexual
relationship with an HIV-infected partner
• A heterosexual man or woman who does
not always use condoms when having sex
with partners known to be at risk for HIV

34. • Anyone who, in the preceding 6 months, has
injected illicit drugs and shared equipment
or been in a treatment program for
injection drug use
• Daily oral PrEP with the fixed-dose
combination of tenofovir disoproxil
fumarate (TDF) 300 mg and emtricitabine
(FTC) 200 mg (Truvada) has been shown to
be safe and effective

35. Vaccination efforts
• The initial hope of an effective vaccine against
HIV has not been fulfilled
• A study from Thailand suggests a possible
benefit of vaccines in heterosexuals at risk for
HIV-1 transmission.

36. • double-blind, placebo-controlled trial by
Rerks-Ngarm et al, 16,402 healthy
participants aged 18-30 years received
either 4 priming injections of recombinant
canarypox vector vaccine (ALVAC-HIV
[vCP1521]) plus 2 booster shots of
recombinant glycoprotein 120 subunit
vaccine (AIDSVAX B/E) or placebo.
• the vaccine efficacy was 31.2%.

37. • With respect to risk behavior, analysis of
efficacy found that the combination of the
HIV vaccines, ALVAC-HIV (vCP1521) and
AIDSVAX B/E, was more effective in those
who maintained lower-risk sexual behavior
compared to those that reported high or
increasing-risk behavior.

38. Condoms, Male and Female
• Condoms continue to be an important
element of HIV prevention strategy.
• If used consistently and correctly, they can
be up to 96 percent effective in protecting
against sexually transmitted infections,
including HIV.
• They are available without a prescription

39. Voluntary Medical Male
Circumcision
• Voluntary medical male circumcision
(VMMC) is one of the most powerful and
cost-effective HIV prevention tools
• Studies from 2006 showed that it reduces a
man’s risk of acquiring HIV from a female
partner by up to 60 %

40. • Newly available non-surgical circumcision
devices could also play a role, offering an
alternative to sutures and surgery that some
men may prefer.

41. ‫حديث‬‫الفطرة‬ ‫من‬ ‫خمس‬
• ‫وسلم‬ ‫عليه‬ ‫هللا‬ ‫صلى‬ ‫يقول‬( :‫من‬ ‫خمس‬
،‫االستحداد‬ ،‫الفطرة‬‫والختان‬‫وقص‬
‫األظافر‬ ‫وتقليم‬ ،‫اإلبط‬ ‫ونتف‬ ،‫الشارب‬)

42. • Device Overview
• In 2007, the World Health Organization
and UNAIDS proved that circumcised men
reduce their risk of HIV Infection by 60%
in high risk areas such as Sub-Saharan
Africa.
• . PrePex is the first known device to
facilitate non-surgical MC that can claim
all of the following: No injected anesthesia.
No surgery. No sutures and No sterile
settings.
• .

43. • PrePex was extensively reviewed by the
WHO, with its safety and efficacy validated
in a series of comprehensive, rigorous
studies. For a list of WHO Prequalified
VMMC devices

44. PrePex Device

45. New method for circumsion
• Disposable Male Circumsion
Kit
• LASER Male Circumsion

46. Treatment

47. • Significant advances in antiretroviral
therapy have been made since the
introduction of zidovudine (AZT) in 1987.
• With the advent of highly active
antiretroviral therapy (HAART), HIV-1
infection is now manageable as a chronic
disease in patients who have access to
medication and who achieve durable
virologic suppression.

48. Antiretroviral agents
Classes of antiretroviral agents include the following:
• Nucleoside reverse transcriptase inhibitors (NRTIs)
• Protease inhibitors (PIs)
• Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
• Fusion inhibitors
• CCR5 co-receptor antagonists (entry inhibitors)
• HIV integrase strand transfer inhibitors

49. When to start ART in people
living with HIV
Adults and adolescents (≥10 years)
• Initiate ART if CD4 cell count ≤500
cells/mm3
• • As a priority,
• Severe/advanced HIV (WHO clinical
stage 3 or 4)
• or
• CD4 count ≤350 cells/mm3

50. • Regardless of WHO clinical stage and
CD4
• • Active TB disease
• • HBV coinfection with severe chronic
liver disease
• • Pregnant and breastfeeding women
with HIV
• • HIV-positive individual in a
serodiscordant partnership (to reduce
HIV transmission risk)

51. • Infants <1 year old
• In all , Regardless of WHO clinical
stage and CD4 cell count.

52. • PREGNANCY, CHILDBIRTH &
BREASTFEEDING AND HIV

53. FAST FACTS
• 1-A pregnant woman living with HIV can
pass on the virus to her baby during
pregnancy, childbirth and through
breastfeeding.
• 2-If a woman living with HIV, taking
treatment correctly during pregnancy and
breastfeeding can virtually eliminate the
risk of passing the virus to the baby.
•

54. • 3-Attending antenatal appointments means
you can get tested for HIV and if needed
receive treatment and medical advice to
help keep you and your baby healthy.

55. HIV and breastfeeding

56. • Breast milk contains HIV. However, guidelines
on whether to breastfeed vary depending on
what resources are available to you.
• If you always have access to formula you
should not breastfeed and give formula
instead.
• If you do not have access to formula and clean,
boiled water all of the time, you may be
advised to breastfeed while both mother and
baby are taking antiretroviral treatment.

57. • If you do breastfeed, you must always take
your treatment and exclusively breastfeed
(give breast milk only) for at least 6 months.
• Mixing breast milk and other foods before
this time increases your baby’s risk of HIV.
You can mix-feed your baby after 6 months.

58. Baby have HIV?

59. • Your baby should be tested for HIV at
birth, and again four to six weeks later.
• If the result comes back negative, your
baby should be tested again at 18
months and/or when you have finished
breastfeeding to find out your baby’s
final HIV status.

60. • It is very important to take your baby for
this final HIV test to ensure they are HIV-
negative or to get them on treatment if they
are positive.
• If any of these tests come back positive,
your baby will need to start treatment
straight away.

61. THANK YOU