AIDS

1. HIV in Bundelkhand Region Prof. P.K. Jain MD,MNAMS Professor & Head, DR Awadhesh kr sharma,SR Department of Medicine, M.L.B. Medical College, Jhansi, UP

2. HIV: GLOBAL PERSPECTIVE First diagnosed in United States in 1981. Isolation of HIV virus – 1983. ELISA technique developed to diagnose HIV-1985. HIV :Indian Perspective In 2007, UNAIDS and NACO estimated about 2 million to 3.6 million people living with HIV. About 0.36% of India’s population is living with HIV.

3. HIV in Bundelkhand Region Yr. / Duration No. of Counselling No. of Testing No. of Positive Cases 1/5/01 - 1/12/06 Male 1991 Female 527 Total 2518 Male 1991 Female 527 Total 2518 Male 140 Female 46 Total 186 1/01/07 – 31/08/07 352 144 496 319 118 437 22 17 39 1/09/07 – 30/09/07 66 25 91 47 16 63 01 02 03 01/04/08 – 01/04/09 500 242 742 408 192 600 42 24 66 Total 2909 938 3847 2765 853 3618 205 89 294

4. No. of Patients Counselled – 3847 Male – 2909 Female – 938 HIV Testing - 3618 Male – 2765 Female – 853 Positive Cases - 294 Male – 205 Female - 89

5. Education level of HIV Positive Patients Illiterete 46 1-5 th standard 32 6-8 th standard 46 8-10 th standard 50 11-12 th standard 36 Graduated 13 Post Graduated 5 Seven patients were below 3 yrs. of age.

6. Marital Status of HIV Positive Patients Unmarried 12 Married 170 Widow 9 Divorced / Seperated 12 Living together 140 Seven patients were below 3 yrs. of age.

7. Occupations of HIV Positive Patients Services 20 Ex-Serviceman 9 Housewife 34 Truck/Bus Driver 61 Labourer 22 Farmer 16 Businessman 11 Student 20

8. Clinical Presentation of HIV Positive Patients Nill 8 Recurrent fever 54 Weight Loss 86 Cough 61 Diarrhoea 53 Sexually Transmitted Illness 14 T.B. 34 Other 7

9. Geographical Distribution of HIV Positive Patients in Bundelkhand Region Jhansi – 120 Chhatarpur – 7 Tikamgarh – 4 Sagar – 2 Jalaun – 14 Datia – 3 Firozabad – 1 Hamirpur – 5 Shivpuri – 2 Laltipur – 18 Mahoba – 5 Dabra – 2 Niwari – 1 Banda - 1

10. 2 2 120 18 4 5 7 14 2 3

11. Etiologic Agent Family : Retroviridae Subfamily : Lentivirus There are two types of HIV viruses. HIV-1 & HIV-2 HIV virus is RNA virus containing reverse transcriptase It contain two major envelop proteins. 1. gp 120 – external 2. gp 41 - transmembrane

20. TRANSMISSION BY BLOOD AND BLOOD PRODUCTS HIV can be transmitted to individuals who receive HIV-tainted blood transfusions, blood products, or transplanted tissue as well as to injection drug users who are exposed to HIV while sharing injection paraphernalia such as needles, syringes, the water in which drugs are mixed, or the cotton through which drugs are filtered. It is estimated that 90 to 100% of individuals who were exposed to such HIV contaminated products became infected. Transfusions of whole blood, packed red blood cells, platelets, leukocytes, and plasma are all capable of transmitting HIV infection. In contrast, hyperimmune globulin, hepatitis B immune globulin, plasma-derived hepatitis B vaccine, and Rho immune globulin have not been associated with transmission of HIV infection.

22. OCCUPATIONAL TRANSMISSION OF HIV: HEALTH CARE WORKERS AND LABORATORY WORKERS Risk of HIV transmission following skin puncture from a needle or a sharp object that was contaminated with blood from a person with documented HIV infection is 0.3% and after a mucous membrane exposure it is 0.09% Transmission of HIV through intact skin has not been documented. An increased risk for HIV infection following percutaneous exposures to HIV-infected blood is associated with exposures involving a relatively large quantity of blood, as a procedure that involves a needle placed directly in a vein or artery, or a deep injury. Factors that might be associated with mucocutaneous transmission of HIV include exposure to an unusually large volume of blood, prolonged contact, and a potential portal of entry.

24. MATERNAL-FETAL/INFANT TRANSMISSION HIV infection can be transmitted from an infected mother to her fetus during pregnancy, during delivery, or by breast-feeding. In the absence of prophylactic antiretroviral therapy to the mother during pregnancy, labor, and delivery, and to the fetus following birth , the probability of transmission of HIV from mother to infant/fetus ranges from 15 to 25% in industrialized countries and from 25 to 35% in developing countries. Studies have demonstrated that truncated regimens of zidovudine alone or in combination with lamivudine given to the mother during the last few weeks of pregnancy or even only during labor and delivery, and to the infant for a week or less, reduced transmission to the infant by 50% compared to placebo.

28. TRANSMISSION BY OTHER BODY FLUIDS Although HIV can be isolated typically in low titers from saliva of a small proportion of infected individuals, there is no convincing evidence that saliva can transmit HIV infection, either through kissing or through other exposures, such as occupationally to health care workers. Secretory leukocyte protease inhibitor (SLPI), blocks HIV infection in several cell culture systems, and it is found in saliva at levels that approximate those required for inhibition of HIV in vitro. In this regard, higher salivary levels of SLPI in breast-fed infants were associated with a decreased risk of HIV transmission through breast milk. It has also been suggested that submandibular saliva reduces HIV infectivity by stripping gp120 from the surface of virions, and that saliva-mediated disruption and lysis of HIV-infected cells occurs because of the hypotonicity of oral secretions.

29. Although virus can be identified, if not isolated, from virtually any body fluid, there is no evidence that HIV transmission can occur as a result of exposure to tears, sweat, and urine.

31. PATHOPHYSIOLOGY AND PATHOGENESIS The hallmark of HIV disease is a profound immunodeficiency resulting primarily from a progressive quantitative and qualitative deficiency of the subset of T lymphocytes referred to as helper T cells , or inducer T cells . This subset of T cells is defined phenotypically by the presence on its surface of the CD4 molecule which serves as the primary cellular receptor for HIV. The initial infection of susceptible cells may vary somewhat with the route of infection. Virus that enters directly into the bloodstream via infected blood or blood products (i.e., transfusions, use of contaminated needles for injecting drugs, sharp-object injuries, maternal-to-fetal transmission either intrapartum or perinatally, or sexual intercourse is likely to be cleared from the circulation to the spleen and other lymphoid organs, where it replicates to a critical level and then leads to a burst of viremia that disseminates virus throughout the body.

37. THE ASYMPTOMATIC STAGE — CLINICAL LATENCY Although the length of time from initial infection to the development of clinical disease varies greatly, the median time for untreated patients is 10 years. HIV disease with active virus replication is ongoing and progressive during this asymptomatic period. The rate of disease progression is directly correlated with HIV RNA levels. Patients with high levels of HIV RNA in plasma progress to symptomatic disease faster than do patients with low levels of HIV RNA .

59. Principles of Therapy of HIV Infection 1. Ongoing HIV replication leads to immune system damage and progression to AIDS. 2. Plasma HIV RNA levels indicate the magnitude of HIV replication and the rate of CD4 T cell destruction. CD4 T cell counts indicate the current level of competence of the immune system. 3. Rates of disease progression differ among individuals, and treatment decisions should be individualized based upon plasma HIV RNA levels and CD4 T cell counts. 4. Maximal suppression of viral replication is a goal of therapy; the greater the suppression the less likely the appearance of drug-resistant species. 5. The most effective therapeutic strategies involve the simultaneous initiation of combinations of effective anti-HIV drugs with which the patient has not been previously treated and that are not cross-resistant with antiretroviral agents that the patient has already received.

60. 6. The antiretroviral drugs used in combination regimens should be used according to optimum schedules and dosages. 7. The number of available drugs is limited. Any decisions on antiretroviral therapy have a long-term impact on future options for the patient. 8. Women should receive optimal antiretroviral therapy regardless of pregnancy status. 9. The same principles apply to children and adults. The treatment of HIV-infected children involves unique pharmacologic, virologic, and immunologic considerations. 10. Compliance is an important part of ensuring maximal effect from a given regimen. The simpler the regimen, the easier it is for the patient to be compliant.

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