DR.VANDANA.

MD
ASST PROFESSOR

DEPT OF MICROBIOLOGY KMC, MANIPAL.

Acquired Immuno Deficiency Syndrome

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HISTORY OF HIV
1983 Virus Isolated Dr.Luc Montagneir Pasteur Institute, Paris Dr. Robert C Gallo National Cancer Institute,USA 1984 - Human Immunodeficiency Virus 1986 - First case in India 1988 - First case in Karnataka
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Adults and children estimated to be living with HIV/AIDS at end 2002

Eastern Europe Western Europe & Central Asia

North America

980 000

Caribbean

440 000 1.5 million

570 000 1.2 million East Asia & Pacific North Africa 1.2 million South & Middle East & South-East Asia 550 000 6 million 29.4 million
Sub-Saharan Africa Australia & New Zealand

Latin America

15 000

Total: 42 million
World Health Organization

Estimated adult and child deaths from HIV/AIDS during 2001

North America Western Europe

20Caribbean 000 30 000

Latin America

6 Africa 800 North & Middle East

Eastern Europe & Central Asia East Asia & Pacific

23 000 35 000 South

& South-East Asia Australia & New Zealand

400 000 30 000 Sub-Saharan 2.3 million

Africa

80 000

120

Total: 3 million

Children (<15 years) estimated to be living with HIV/AIDS 2001

North America Western Europe

10Caribbean 000 20 000

Latin America

4 Africa 000 North & Middle East

200 000 20 000 sub-Saharan 2.4 million

Africa

Eastern Europe & Central Asia East Asia & Pacific 15 000 South 7 000 & South-East Asia Australia & New Zealand

40 000

< 200

Total: 2.7 million

HIV/AIDS CURRENT STATUS

40 million cases in 2003
Almost 50% are women 14,000 new infections every day in 2003
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New HIV/AIDS in 2002

North America Eastern Europe Western Europe & Central Asia

45 000

Caribbean

60 000

30 000 250 000 East Asia & Pacific North Africa 270 000 & Middle East South & South-East Asia 83 000 700 000
Sub-Saharan Africa

Latin America

150 000

3.5 million

Australia & New Zealand

500

Total: 5 million
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AIDS Cases Karnataka (1987 - 2003)

1400 1200 1000 800 600 400 200 0 Cumulative number
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1368
Male Female

339

Human Immunodeficiency Virus (HIV)

Retroviridae R N A Virus Reverse Transcriptase enzyme Viral Proteins
Gag (group Specific Antigens) Pol (Enzymes) Env (Envelope Proteins)
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HIV Viral Structure

Envelop

Core

gp120 gp41

p17 (matrix) p24 (capsid) p7/p9

(nucleocapsid)

HIV Enzymes

HIV RNA
Diploid single strand RNAs

RT Integrase Protease

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Origin Of HIV ?????

? African Monkeys Similar Viruses in Monkeys Simian Immunodeficiency Virus SIV HIV Do not cause AIDS in Monkeys

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HIV Groups and Subtypes

HIV
HIV-1 Group O Group N Group M

HIV-2

Subtypes A-J Subtypes A-F

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Global Molecular Epidemiology of HIV Infection

E. Europe Central Asia 420,000 East Europe and Central Asia 53,000

N. America 900,000

W. Europe 520,000

B ACDFO
HIV-2

N. Africa Middle East 220,000 Caribbean 360,000

Latin America 1.3 million

B FC BE

B B O DGH C A D E/A C AD
Sub-Saharan Africa 24.5 million

B ACDGH B C B E B, E CB E E/A,B E/A B

South and SE Asia 5.6 million

East Asia and Pacific 530,000

B
Australia and New Zealand 15,000

Global Total : 34.3 million of HIV-infected Adults and Children

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Source: UNAIDS/WHO 2000, Weniger B, et al 1994

Other Countries Reporting HIV-2 Infections

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HIV-2 Background
HIV-2 first isolated 1986 West Africa
HIV1 and HIV-2 60-70% homologous HIV-2 has six subtypes (A-F)

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HIV-2 Clinical Aspects

less transmissible
vertical rate 20-35% for HIV-1 vs. <4% for HIV-2

progress more slowly to AIDS

Less mortality
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Mode of Transmission
Unprotected sex Blood and Blood Products Mother to Child Transmission Contaminated Needles Injectable Drug Use
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Mode of Transmission
Sex Blood & Blood Products Syringe & Needle Perinatal Others

4% 0% 2%

77%

17%

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Efficiency of Transmission
Exposure route Sexual intercourse Blood transfusion Perinatal Efficiency (%) 0.1 - 1 90 - 95 20 40

IVDU Needle stick exposure

0.5 1 <.05
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Cellular Targets of HIV Infection

Major Targets, In Vivo :
CD4+ T lymphocytes Monoctyes/macrophages

Minor Targets, In Vivo :

Langerhans cells, CD34+ monoctye precursors, triple negative (CD3/CD4/CD8) thymocytes, dendritic cells

Mostly In Vitro :
FDC, CD8, B cells, NK cells, megakaryocytes Astrocytes, oligodendrocytes, microglial cells Rectal mucosal, bowel mucosal cells Cervical cells, trophoblasts, testis, prostrate Others: liver, lung, heart, salivary gland, adrenal gland
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What are CD4 and CD8 T cells?

Cytotoxic cells
Helper Cells
T4 CD4 MHC II Induction of Antibody system (B cells) Facilitates Tc production of IL2, 6
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T8 CD8 MHC I Lysis of antigen bearing target cells

HIV-1 Cell Tropism

Virus Target (cell type)

M-tropic (R5)
Monocytes Macrophages Microglial cells Primary T cells NSI CCR-5
CCR2b, CCR-3

T-tropic (X4)
T cell lines Primary T-cells

Syncytium Co-receptors Clinical Stage

SI CXCR-4 (fusin)
CCR2b, CCR-3

Transmitting virus Acute, early

Advanced Drug resistance

The Mechanism of HIV Entry

by Robert Doms 1998

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HIV-NAT

HIV Life Cycle and Replication

N Engl J Med 1999 May 27;340(21):1614-22

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HIV Infection via Mucosa Intact mucosa ? R5 virus infects dendritic cells Transport of virus to regional LN Transmit to CD4+ T cells in regional LN
Walker et al. NEJM 1998

HIV Infection

Lymph nodes Viremia Dissemination to other organs Brain Spleen Gut

Viral Escape from Host Defense

HIV has an extraordinary ability to mutate
Immune escape : from neutralizing Ab, CTLs

Latently infected resting memory CD4+ cells

Can live longer than 3 years or indefinitely

HIV-specific CTL is paradoxically segregated in peripheral blood > lymphoid tissues

(whereas HIV infection is mainly occurred in L.N.)

Hypothesis of why HIV can not be cleared by immune system in almost all patients
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HIV-Neutralizing Antibody and CTL

Neutralizing Antibody

HLA class I

CTL

CD8+ T-cell
CD4+ Helper T-cell

HIV-infected cell

PROGRESSION OF DISEASE
I N ARS WINDOW PERIOD F E C T 2-4 0-6 I weeks O N Fever or Diarrhea
HIV POSITIVE ASYMPTOMATIC PERIOD HIV POSITIVE SYMPTOMATIC PERIOD

AIDS

6wks 2-5 yrs

2-3 years

1-12mth

D E A T H

Lasts 2 3 days

Lasts 2-3 weeks

Lasts 2 3 mnths

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Natural Course of HIV Infection and Common Complications 1000 900

CD4+ cell Count

Asymptomatic
CD4+ T cells

800 700 600 Acute HIV infection syndrome

Relative level of Plasma HIV-RNA

TB

500
400 300 200 100 0

HZV
OHL OC

PPE
TB
0 1 2 3 4 5 1 2 3 4 5 6 7

PCP CM CMV, MAC 8 9 10 11

Months

Years After HIV Infection

Patterns of HIV Disease Progression

Typical Progressors
90 %

7-10 years
<3 years

HIV Infection

Rapid Progressors
<5 %

Long-term Non-progressors
<10 %

>10-15 yr
Normal, Stable CD4

Long-term Survivals

>10 yr
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N.A.C.O. Clinical case definition of AIDS

A: Two positive tests of HIV (E/R/S) B: Any one of the following:
Significant Weight loss (>10% in 1 month) Chronic Diarrhea (Intermittent / persistent) Prolonged fever (> 1 month Intermittent / continuous) Disseminated, miliary, extra-pulmonary, extensive tuberculosis Neurological impairment Oro-pharyngeal candidiasis

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CASE DEFINITION OF A.I.D.S.

Life threatening or recurrent pneumonia Cryptococcal meningitis Neurotoxoplamosis Cytomegalovirus retinitis Recurrent or multi-dermatomal Herpes Penicillium marnefei Disseminated molluscum Kaposis sarcoma

zoster

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Early symptoms
Weight loss Fever Night Sweats Diarrhea Skin disorders early
Fungal Pruriginous dermatitis Varicella
Grant AD et al BMJ 2001
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OPPORTUNISTIC INFECTIONS

Bacterial
Mycobacterrium spp, Salmonellae, Listeria,pneumococci,Campylobacter

Viral
HSV, VZV, CMV, EBV,Adeno
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contd
Fungal
Candida, Cryptococcus, Pneumocystis carinii,Histoplasma, Penicillium marneffii

Parasitic
Toxoplasma,Isospora,Cryptosporidium, Microsporiridia, Giardia, Strongyloides
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MALIGNANCIES
Kaposi sarcoma
NHL Primary lymphoma of CNS Anogenital neoplasia
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Diagnostic Tests available

Serology Screening
ELISA Rapid

Confirmatory
Western Blot/ Immunoblot

Virology Viral culture Antigen p24 detection PCR DNA/RNA Surrogate markers

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Accuracy of tests
False positive
Auto-immune disease Vaccination Rate with ELISA-

False negative
Acute sero-converting illness ASI Late HIV infection HIV-2 Unusual serotypes Serotype O Rate with ELISA- 0.3%

0.0007%

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Testing strategies
Strategy I: A single ELISA or Rapid Test is used. Eg., Blood screening before transfusion Strategy II: Two ELISA or rapid tests are necessary to report result as POSITIVE
Eg., Surveillance and Research, clinical diagnosis in patients with symptoms suggestive of AIDS

Strategy III: Three ELISA or rapid tests are necessary to declare the result as positive Eg.,: Clinical diagnosis in asymptomatic patients such as in VCTC and
PPTCT program
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ELISA
Easy to perform, sensitive, specific and cost effective False positives in autoimmune disease, multiple transfusions, hypergammaglobulinemia, alcoholic hepatitis, vaccination False negatives in window period,rare subtypes, late stages, technical error.
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RAPID ASSAYS
Equally sensitive and specific.
Require less than 30 min and simple to perform.

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WESTERN BLOT ASSAY

Confirms ELISA reactivity Less sensitive than ELISA In initial seroconversion Presence of any two of the gp41, p24 and gp120/160 bands is considered reactive. Reactive bands that do not meet above criteria is termed indetrminate.
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SURROGATE MARKERS
CD4 count
Neopterin
Beta-2 microglobulin

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P24 ANTIGEN DETECTION

Blood screening Identifying acute infection Monitor HIV infection Detection of infection in newborn Monitor antiretroviral therapy?

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HIV DNA/RNA DETECTION AND QUANTIFICATION

DNA PCR / RNA PCR. NASBA Branched chain DNA
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CLINICAL UTILITY
Predicts disease progression Correlates with clinical outcome in treatment studies Diagnosis in children < 18 months. Evaluate patients with indeterminate serological assays

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Indeterminate test result

Single positive ELISA or single band on Western blot test Indeterminate test in low risk population usually no HIV infection Could also represent ASI Repeat test may show persistence of indeterminate result Follow-up testing with Western blot test, ELISA or PCR
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Prevention
Safe COITUS Blood Safety PMTCT Universal Precautions Post exposure prophylaxis
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PRIMARY PREVENTION OF SEXUAL TRANSMISSION OF HIV

Abstinence : Delay onset of sexual activity Be faithful: Reduce number of partners Condoms: Use condoms correctly, consistently
Get STD patients & partners treated promptly & completely

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PREVENTION OF BLOOD BORNE HIV TRANSMISSION

Prevent blood to blood contact and blood to mucous membrane contact and blood to broken skin contact All blood to be tested before transfusion/ donation. Needle distribution among IVDUs harm reduction strategies. Universal or standard precautions in Health care. Post-Exposure Prophylaxis (PEP) in Health care.

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HIV TRANSMISSION Mother to Child

Risk of transmission 30 - 35%
Within the womb = about 5% (very small) During delivery = 15-20% During breast feeding = 10-15%
PPTCT = USING A.R.T. IN THE MOTHER & CHILD REDUCES THE RISK OF TRANSMISSION.

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Risk of Transmission Blood borne viruses

Human immunodeficiency virus (HIV) Percutaneous exposure Mucocutaneous exposure
Hepatitis B virus (HBV) Percutaneous exposure Hepatitis C virus (HCV) Percutaneous exposure 0.05- 0.4 % 0.006 - 0.05%

9 - 30%

3 - 10%
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UNIVERSAL PRECAUTIONS
APPLY TO THESE FLUIDS: Blood Semen/Vaginal fluids Breast milk CSF Amniotic fluids Peritoneal/pericardial Synovial fluids DO NOT APPLY TO THESE: Saliva Tears Sweat Sputum & nasal fluids Vomitus Urine Faeces

Unless mixed with visible blood

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UNIVERSAL PRECAUTIONS
DOs
Wash hands after every procedure Wear gloves when in contact with infectious body fluids Use protective eye wear & mask when expecting blood splash Use aprons when in continuous contact with infectious fluids Dispose sharps in a puncture proof container

DONTs
Never re-use unsterilised needles. Never recap needles Do not bend or try to break needles with hand Avoid direct contact with fluids, when injured. Never pass sharps by hand

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DISPOSAL OF HOSPITAL WASTES

All sharps must be disposed of in puncture proof containers Organic wastes such as dressings, placenta, blood bags, IV line, catheter must be incinerated Urine, stool and vomitus may be disposed down the drain

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POST EXPOSURE PROPHYLAXIS FOR OCCUPATIONAL EXPOSURE

An occupational exposure is one where a Health Care Worker has been exposed to risk of HIV infection by a percutaneous injury, contact of mucous membrane or contact of broken skin or the contact is prolonged or involving an extensive area with blood, tissue or other body fluids to which universal precautions apply.

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WHAT TO DO IN THE EVENT OF OCCUPATIONAL EXPOSURE?

Do not panic! Do not put pricked finger in mouth Wash with soap and water - bleach not required. Report the injury immediately PEP should begin within 2 hours. PEP is not recommended after 72 hours

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TREATMENT OF AIDS
Antiretroviral therapy NRTI: Zidovudine,Didanosine,Zalcitabine,Stavudine, Lamivudine. NNRTI : Nevirapine, Delavirdine, Efavirenz PI : Saquinavir, Ritonavir, Indinavir, Nelfinavir. Treatment of opportunistic infections

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HIV VACCINES
Ideal vaccine:
prevent transmission by mucosal and parenteral routes Excellent safety profile Low cost Stability and ease of administration Protection against diverse viral isolates
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Realities
Sequence variation Protective immunity Latency Transmission Lack of suitable animal model

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VACCINE APPROACHES
Recombinant subunit vaccine Live recombinant vaccine Whole inactivated vaccine Pseudovirions and virus like particles Peptide based vaccine DNA vaccine
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