hiv infection patrick duff, m.d. university of florida hiv

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HIV INFECTION

• PATRICK DUFF, M.D.
• UNIVERSITY OF FLORIDA

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HIV INFECTION LEARNING OBJECTIVES

• Describe the pathophysiology of HIV infection.
• Describe the principal mechanisms of transmission
  of HIV infection.
• Describe the diagnostic algorithm for HIV
  infection.
• Describe measures for prevention and treatment of
  HIV infection.

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HIV INFECTIONKEY QUESTIONS

• Most common mechanisms of transmission
• Diagnostic algorithm
• Indications for treatment
• Preventive measures

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HIV INFECTIONVIRAL STRUCTURE
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HIV INFECTIONVIROLOGY

• RNA retrovirus
• Two major strains
• HIV-1
• HIV-2

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HIV INFECTION VIRAL STRUCTURE
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HIV INFECTIONKEY VIRAL ENZYMES

• Reverse transcriptase
• Integrase
• Protease

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HIV INFECTIONPATHOPHYSIOLOGY
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HIV INFECTIONPATHOPHYSIOLOGY
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HIV INFECTIONGENETIC DIVERSITY

• Replication cycle - 2.5 days
• 1 billion virions each day
• 10 trillion virions during course of illness
• Replication errors?changes in genome?drug
  resistance

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STAGES OF HIV INFECTION

• Acute retroviral illness?
• Latent phase?
• Symptomatic phase?
• AIDS? fatal outcome

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MOST COMMON SERIOUS OPPORTUNISTIC DISEASES

• Pneumocystis jiroveci(carinii) pneumonia
• Kaposis sarcoma
• MAC

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OTHER IMPORTANT OPPORTUNISTIC DISEASES

• TB
• Toxoplasmosis
• CMV infection
• Candidiasis
• Non-Hodgkins lymphoma

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PRINCIPAL MECHANISMS OF TRANSMISSION

• Sexual contact
• IVDU
• Perinatal

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EPIDEMIOLOGY OF HIV INFECTION
Million cases
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EPIDEMIOLOGY OF HIV INFECTION IN THE U.S.
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EPIDEMIOLOGY OF HIV INFECTION IN MEN IN THE U.S.
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EPIDEMIOLOGY OF HIV INFECTION IN MEN IN THE U.S.
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EPIDEMIOLOGY OF HIV INFECTION IN WOMEN
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EPIDEMIOLOGY OF HIV INFECTION IN WOMEN
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RISK FACTORS FOR SEXUAL TRANSMISSION

• Multiple sexual partners
• Receptive anal intercourse
• Unprotected intercourse
• IVDU

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RISK FACTORS FOR SEXUAL TRANSMISSION

• Crack cocaine use
• Ulcerated genital lesions
• Uncircumcised male

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RISK FACTORS FOR SEXUAL TRANSMISSION

• Severity of illness in index case
• Sex during menstruation
• Bleeding during intercourse

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DIAGNOSIS OF HIV INFECTION

• Screening test enzyme immunoassay (EIA)
• Western blot
• IFA
• Test for p24 antigen and viral antibody

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DIAGNOSIS OF HIV INFECTION
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DIAGNOSIS OF HIV INFECTION

• Frequency of false-positive test is less than
  110,000
• Explanation for false-negative test
• Early in disease? no antibody response
• Severe immunosuppression? no antibody response
  (anergy)

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ETIOLOGY OF PEDIATRIC HIV INFECTION
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MECHANISMS OF PERINATAL TRANSMISSION OF HIV
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FREQUENCY OF VERTICAL TRANSMISSION OF HIV
Percent
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HIV INFECTIONMANAGEMENT

• Antiretroviral therapy
• Prophylactic antibiotics
• Immunizations

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HIV INFECTIONANTIRETROVIRAL AGENTS

• Nucleoside reverse transcriptase inhibitors
• Non-nucleoside reverse transcriptase inhibitors
• Protease inhibitors
• Entry (fusion) inhibitors
• Integrase inhibitors

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HIV INFECTIONCRITERIA FOR TREATMENT

• Early symptomatic illness
• CD 4 count lt 200/mm 3
• Relatively high viral load (gt 30,000 copies/ml)
• Later symptomatic illness
• Pregnancy prevention of perinatal transmission

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HIV INFECTIONEFFECTS OF TREATMENT

• Prolonged survival
• Improved quality of life

Level I evidence
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HIV INFECTIONPROPHYLACTIC ANTIBIOTICS
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HIV INFECTIONPROPHYLACTIC ANTIBIOTICS
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HIV INFECTIONVACCINATIONS

• Hepatitis A
• Hepatitis B
• Meningococcal vaccine

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HIV INFECTIONVACCINATIONS

• Pneumococcal vaccine
• Influenza vaccine
• Seasonal flu
• H1N1

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PREVENTION OF HIV INFECTION
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PREVENTION OF HIV INFECTION

• Avoid IVDU
• Avoid occupational injury

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PREVENTION OF HIV INFECTION
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PREVENTION OF INFECTION
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POST SEXUAL EXPOSURE PROPHYLAXIS

• Drugs combination chemotherapy
• Duration - 28 days
• Cost approximately 1000

Level III evidence
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RISK FACTORS FOR OCCUPATIONAL INFECTION

• Deep injury
• Visible blood on the device
• Indwelling needle in artery or vein
• Terminal illness in source patient
• Failure to receive prophylaxis

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PROPHYLAXIS FOR OCCUPATIONAL EXPOSURE

• High risk 3 or 4 drug regimen
• Low risk - ZDV 3TC (Combivir)

Level II evidence
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HIV INFECTIONCONCLUSIONS

• HIV infection is one of the major public health
  problems in the world
• Preventive measures are essential
• Treatment is effective but not curative

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HIV INFECTIONKEY QUESTIONS

• Most common mechanisms of transmission
• Diagnostic algorithm
• Indications for treatment
• Preventive measures

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HIV INFECTIONSUGGESTED READING

• ACOG Committee Opinion. No. 232, May 2000.
• JAMA 2004292219-23
• NEJM 2000 3421416-29.

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HIV INFECTIONSUGGESTED READING

• Obstet Gynecol 2003 101797-810.
• Obstet Gynecol 2002 991117-26.
• JAMA 2002 288 222-35.