HUMAN

IMMUNODEFICIENCY VIRUS
(HIV)
Introduction
Discovered independently by Luc Montagnier
of France and Robert Gallo of the US in 1983-
84.
Former names of the virus include:
Human T cell lymphotrophic virus (HTLV-III)
Lymphadenopathy associated virus (LAV)
AIDS associated retrovirus (ARV)
Introduction
HIV-2 discovered in 1986, antigenically distinct
virus endemic in West Africa.
The first case of HIV infection in the
Philippines was reported in 1984. From
January 1984 to September 2015, there has
been 28,428 HIV Ab sero-positive cases
reported.
Most (26,066 or 92%) were male.
Introduction

The age group with the biggest proportion of

cases has become younger: from 2000 to
2004, it was 30-39 years; from 2005 to 2009, it
was 25-34 years; and from 2010 to 2015, it
was 20-29 years. Notably, the proportion of
PLHIV in the 15-24 year age group increased
from 20% in 2005-2009 to 28% in 2010-2015.
Characteristics of the virus
Icosahedral (20 sided), enveloped virus of the
lentivirus subfamily of retroviruses.
Retroviruses transcribe RNA to DNA.
Two viral strands of RNA found in core
surrounded by protein outer coat.
Outer envelope contains a lipid matrix within which
specific viral glycoproteins are imbedded.
These knob-like structures responsible for binding to
target cell.
Characteristics of the virus
HIV

The outer shell of the virus is

known as the Viral envelope.
Embedded in the viral
envelope is a complex protein
known as env which consists
of an outer protruding cap
glycoprotein (gp) 120, and a
stem gp14. Within the viral
envelope is an HIV protein
called p17(matrix), and within
this is the viral core or capsid,
which is made of another viral
protein p24(core antigen).
Structural Genes
Three main structural genes:
Group Specific Antigen (Gag)
Envelope (Env)

Polymerase (Pol)
Group Specific Antigen (Gag)
Located in nucelocapsid of virus.
Icosahedryl capsid surrounds the internal
nucleic acids made up of p24 and p15.
p17 lies between protein core and envelope
and is embedded in the internal portion of the
envelope.
Two additional p55 products, p7 and p9, are
nucleic acid binding proteins closely
associated with the RNA.
Envelope (Env)
Envelope (Env) gene codes for envelope
proteins gp160, gp120 and gp41.
These polyproteins will eventually be cleaved by
proteases to become HIV envelope glycoproteins
gp120 and gp41.
gp160 cleaved to form gp120 and gp41.
gp120 forms the 72 knobs which protrude from outer
envelope.
gp41 is a transmembrane glycoprotein antigen that
spans the inner and outer membranes and attaches to
gp120.
gp120 and gp41 both involved with fusion and
attachment of HIV to CD4 antigen on host cells.
Polymerase (Pol)
Polymerase (Pol) codes for p66 and p51
subunits of reverse transcriptase and p31 an
endonuclease.
Located in the core, close to nucleic acids.
Responsible for conversion of viral RNA into
DNA, integration of DNA into host cell DNA and
cleavage of protein precursors.
Viral Replication
First step, HIV attaches to susceptible host cell.
Site of attachment is the CD4 antigen found on a
variety of cells
helper T cells
macrophages
monocytes
B cells
microglial brain cells
intestinal cells
Life Cycle
Viral Replication
The gp120 protein on virus binds specifically
to CD4 receptor on host cell with high affinity.
Gp41 causes fusion of the virus to the cell
membrane.
After fusion virus particle enters cell.
Viral genome exposed by uncoating particle.
Viral Replication
Reverse transcriptase produces viral DNA
from RNA.
Becomes a provirus which integrates into host
DNA.
Period of latency occurs.
Viral Replication
After a period of latency lasting up to 10 years
viral replication is triggered and occurs at high
rate.
CD4 cell may be destroyed in the process, body
attempts to replace lost CD4 cells, but over the
course of many years body is unable to keep
the count at a safe level.
Destruction of large numbers of CD4 cause
symptoms of HIV to appear with increased
susceptibility to opportunistic infections, disease
and malignancy.
HIV (arrows) Infecting a T-lymphocyte
Viral Replication
Methods of transmission:
Sexual transmission, presence of STD increases
likelihood of transmission.
Exposure to infected blood or blood products.

Use of contaminated clotting factors by hemophiliacs.

Sharing contaminated needles (IV drug users).

Transplantation of infected tissues or organs.

Mother to fetus, perinatal transmission variable,

dependent on viral load and mothers CD 4 count.
Primary HIV Syndrome
Mononucleosis-like, cold or flu-like symptoms
may occur 6 to 12 weeks after infection.
lymphadenopathy
fever
rash
headache
Fatigue
diarrhea
sore throat
neurologic manifestations.
no symptoms may be present
Primary HIV Syndrome
Symptoms are relatively nonspecific.
HIV antibody test often negative but becomes
positive within 3 to 6 months, this process is
known as seroconversion.
Large amount of HIV in the peripheral blood.
Primary HIV can be diagnosed using viral load
titer assay or other tests.
Primary HIV syndrome resolves itself and HIV
infected person remains asymptomatic for a
prolonged period of time, often years.
Clinical Latency Period
HIV continues to reproduce, CD4 count
gradually declines from its normal value of 500-
1200.
Once CD4 count drops below 500, HIV infected
person at risk for opportunistic infections.
The following diseases are predictive of the
progression to AIDS:
persistent herpes-zoster infection (shingles)
oral candidiasis (thrush)
oral hairy leukoplakia
Kaposis sarcoma (KS)
Oral Candidiasis (thrush)
Oral Hairy Leukoplakia

Being that HIV reduces immunologic activity, the intraoral

environment is a prime target for chronic secondary
infections and inflammatory processes, including OHL,
which is due to the Epstein-Barr virus under
immunosuppressed conditions
Kaposis sarcoma (KS)
Kaposis sarcoma
(shown) is a rare cancer
of the blood vessels that
is associated with HIV. It
manifests as bluish-red
oval-shaped patches that
may eventually become
thickened. Lesions may
appear singly or in
clusters.
AIDS
CD4 count drops below 200 person is considered to
have advanced HIV disease
If preventative medications not started the HIV infected
person is now at risk for:
Pneumocystis carinii pneumonia (PCP)
cryptococcal meningitis
toxoplasmosis
If CD4 count drops below 50:
Mycobacterium avium
Cytomegalovirus infections
lymphoma
dementia
Most deaths occur with CD4 counts below 50.
Other Opportunistic Infections
Respiratory system
Pneumocystis Carinii Pneumonia (PCP)
Tuberculosis (TB)
Kaposi's Sarcoma (KS)
Gastro-intestinal system
Cryptosporidiosis
Candida
Cytomegolavirus (CMV)
Isosporiasis
Kaposi's Sarcoma
Other Opportunistic Infections
Central/peripheral Nervous system
Cytomegolavirus
Toxoplasmosis
Cryptococcosis
Non Hodgkin's lymphoma
Varicella Zoster
Herpes simplex
Skin
Herpes simple
Kaposi's sarcoma
Varicella Zoster
Immunologic Manifestations
Early stage slight depression of CD4 count,
few symptoms, temporary.
Window of up to 6 weeks before antibody is
detected, by 6 months 95% positive.
During window p24 antigen present, acute
viremia and antigenemia.
Immunologic Manifestations
Antibodies produced to all major antigens.
Firstantibodies detected produced against gag
proteins p24 and p55.
Followed by antibody to p51, p120 and gp41

As disease progresses antibody levels decrease.

Immunologic Manifestations
Immune abnormalities associated with
increased viral replication.
Decrease in CD4 cells due to virus budding from cells,
fusion of uninfected cells with virally infected cells and
apoptosis.
B cells have decreased response to antigens possibly
due to blockage of T cell/B cell interaction by binding
of viral proteins to CD4 site.
CD8 cells initially increase and may remain elevated.
As HIV infection progresses, CD4 T cells drop
resulting in immunosuppression and susceptibility of
patient to opportunistic infections.
Death comes due to immuno-incompetence.
Sustiva + Truvada Treatment
Sustiva + Truvada (FTC + tenofovor) is one of the most
popular and effective starting HIV regimens.
Many patients will have dream/sleep/central nervous
system effects particularly in the first month (due to the
Sustiva).
Upset stomach/bloating/gas/loose stools is also fairly
common during the first month and for most patients is
fairly mild.
HIV levels in the blood will often drop by > 99% in the
first month and the CD4 count (marker of immune
system function) will often increase providing protection
against AIDS related diseases within weeks/months of
starting the medication.
Truvada
Truvada is made up of HIV drugs from a class
called nucleoside/nucleotide reverse
transcriptase inhibitors (NRTIs), also known as
nukes.
The NRTIs block reverse transcriptase, a
protein that HIV needs to make more copies of
itself. This may slow down HIV disease
Laboratory Diagnosis of HIV Infection

Methods utilized to detect:

Antibody

Antigen

Viralnucleic acid
Virus in culture
ELISA Testing
First serological test developed to detect HIV
infection.
Easy to perform.
Easily adapted to batch testing.
Highly sensitive and specific.

Antibodies detected in ELISA include those

directed against: p24, gp120, gp160 and gp41,
detected first in infection and appear in most
individuals
ELISA Testing
ELISA tests useful for:
Screening blood products.
Diagnosing and monitoring patients.

Determining prevalence of infection.

Research investigations.
ELISA Testing
Different types of ELISA techniques used:
indirect

competitive

sandwich

ELISAs are for screening only, false positives

do occur and may be due to AI disease,
alcoholism, syphilis, and immunoproliferative
diseases.
Other Screening Tests
Agglutination tests using latex particles, gelatin
particles or microbeads are coated with HIV
antigen and will agglutinate in the presence of
antibody.
Dot-Blot Testing utilizes paper or nitrocellulose
impregnated with antigen, patient serum is
filtered through, and anti-antibody is added with
enzyme label, color change is positive.
A rapid, cost-effective and may become an alternative
to standard ELISA and Western blot testing.
Particle Agglutination
Western Blot
Most popular confirmatory test.
Utilizes a lysate prepared from HIV virus.
The lysate is electrophoresed to separate out the HIV
proteins (antigens).
The paper is cut into strips and reacted with test sera.
After incubation and washing anti-antibody tagged
with radioisotope or enzyme is added.
Specific bands form where antibody has reacted with
different antigens.
Most critical reagent of test is purest quality HIV
antigen.
The following antigens must be present: p17, p24,
p31, gp41, p51, p55, p66, gp120 and gp160.
Western Blot
Antibodies to p24 and p55 appear earliest but
decrease or become undetectable.
Antibodies to gp31, gp41, gp 120, and gp160
appear later but are present throughout all
stages of the disease.
Western Blot
Interpretation of results.
No bands, negative.
In order to be interpreted as positive a minimum
of 3 bands directed against the following antigens
must be present: p24, p31, gp41 or gp120/160.
CDC criteria require 2 bands of the following:
p24, gp41 or gp120/160.
Western Blot
Expensive $ 80 - 100
technically more difficult
Gold Standard for
confirmation
Indirect immunofluorescence
Can be used to detect both virus and antibody
to it.
Antibody detected by testing patient serum
against antigen applied to a slide, incubated,
washed and a fluorescent antibody added.
Virus is detected by fixing patient cells to slide,
incubating with antibody.
Detection of p24 HIV antigen
The p24-antigen screening assay is an EIA
performed on serum or plasma.
P24 antigen only present for short time,
disappears when antibody to p24 appears.
Anti-HIV-1 bound to membrane, incubated with
patient serum, second anti-HIV-1 antibody
attached to enzyme label is added (sandwich
technique), color change occurs.
Optical density measured, standard curve
prepared to quantitate results.
Detection of p24 HIV antigen
Positive confirmed by neutralizing reaction,
preincubate patient sample with anti- HIV,
retest, if p24 present immune complexes form
preventing binding to HIV antibody on
membrane when added.
Test not recommended for routine screening
as appearance and rate of rise are
unpredictable.
Sensitivity lower than ELISA.
Detection of p24 HIV antigen
Most useful for the following:
earlyinfection suspected in seronegative patient
newborns

CSF

monitoring disease progress

Polymerase Chain Reaction (PCR)
Looks for HIV DNA in the WBCs of a person.
PCR amplifies tiny quantities of the HIV DNA present,
each cycle of PCR results in doubling of the DNA
sequences present.
The DNA is detected by using radioactive or biotinylated
probes.
Once DNA is amplified it is placed on nitrocellulose
paper and allowed to react with a radiolabeled probe, a
single stranded DNA fragment unique to HIV, which will
hybridize with the patients HIV DNA if present.
Radioactivity is determined.
Virus isolation
Virus isolation can be used to definitively
diagnose HIV.
Best sample is peripheral blood, but can use
CSF, saliva, cervical secretions, semen, tears or
material from organ biopsy.
Cell growth in culture is stimulated, amplifies
number of cells releasing virus.
Cultures incubated one month, infection
confirmed by detecting reverse transcriptase or
p24 antigen in supernatant.
Viral Load Tests
Viral load or viral burden is the quantity of HIV-
RNA that is in the blood.
RNA is the genetic material of HIV that
contains information to make more virus.
Viral Load Tests
Viral load tests measure the amount of HIV-RNA
in one milliliter of blood.
Take 2 measurements 2-3 weeks apart to
determine baseline.
Repeat every 3-6 months in conjunction with
CD4 counts to monitor viral load ant T-cell
count.
Repeat 4-6 weeks after starting or changing
antiretroviral therapy to determine effect on viral
load.
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