Specific Investigations of HIV Infections

1.

Antigen Detection: The detection of HIV p24 antigen in serum or CSF is the key to early diagnosis. The p24 antigen is a soluble protein from core of virus. Its level increases during first few weeks and level detected upto six weeks time. The antigen is not detected during asymptomatic silent phase for a period of ten years or more. The reappearance of p24 antigen precedes onset of symtomatic phase of AIDS.
Antibody Test: Detection of the IgG antibody to envelop components gp 120 and its sub units is the commonly employed marker of infection with HIV. It is detected in the patient serum using enzymelinked immunosorbent assay (ELISA). This test is highly sensitive (> 99.5%) and quite specific.

2.

3.

Western Blot (Immunoblotting): The confirmation of positive ELISA test by this is mandatory. It detects the presence of antibodies in the patients serum against HIV antigen. The criteria for the positive interpretation of western blot test are the presence of any two of three bands; i, anti p24 ii, anti gp41 and iii, anti gp 120 or gp 160 Polymerase Chain Reaction: It detects very low level of viral DNA integrated into the host genome. It is useful test in patients with +ve or intermediate ELISA test. Virus Isolation: HIV can be cultured from tissue peripheral blood cells or plasma but this is mostly done in research settings.

4.

5.

6.

CT Scan or MRI: It is a advanced investigated procedure done in patients with headache or neurological science so as to exclude intracerebral lesions before a lumber puncture is performed. HIV Genotypic or Phenotypic Resistance Test: It is useful in deciding the choice of antiretroviral regimen in treatment of HIV infection.

7.

8.

CD4 + T-cell Count: During the course of HIV disease there is gradual reduction in the CD4 cells in the peripheral blood while the CD8 cell count remains unchanged. The CD4 cell count is an important criteria as its level falls below 200/L, patient should be placed on regimen for pneumocystis carinii infection prophylaxis.

BASELINE INVESTIGATIONS FOR HIV INFECTION

1.

Microbiology: Serological test for syphillis toxoplasmosis, cryptococcal antigens.

2. Virology: HIV antibody (confirmatory), hepatitis

serology (B & C), cytomegalovirus antibody.

3. Haematology: Total and differential leucocytes count

and peripheral blood film examination, ESR.

4. Biochemistry: Liver and renal function test. 5. Immunology: Lymphocytes subsets (CD4 & CD8

count), 2 microglobulin.
6. Miscellaneous: X-ray chest, lymph node biopsy and

cytology and lung function tests.

TREATMENT
General principles of patient management include

counselling psychological support and screening for HIV infection. The general guidelines for treatment of adults are as follows: Stage 1: Acute HIV Syndrome 1,,Symtomatic treatment of illness 2, Appropriate diagnostic test for TB, hepatitis B, syphilis 3, Vaccination and immunization

 Stage 2: Chronic asymtomatic infection; Antiretroviral therapy; The corner stone of medical management of HIV infection is

antiretroviral therapy. Suppression of HIV replication is important component in prolonging life and improving quality of life of patients with HIV infection A. Nucleoside Analogues:
1.

Zidovudine (AZT, 3-azido, 2-3 dideoxythymidine) Doses: 200mg tid or 300mg bid It inhibit reverse transcriptase and act as DNA chain terminator

2. Didanosine (dideoxyinosine)

Doses: 200mg bid for patients > 60kg and 100mg bid for patients < 60kg 3. Zalcitabine (dideoxycytidine) Doses: 0.75mg tid
4. Stavudine (didehydro-3-deoxy-thymidine)

Doses: 40mg bid 5. Lamivudine Doses: 150mg bid

B. Nonnucleoside reverse transcriptase inhibitors:

These interfere with function of HIV reverse transcriptase by binding two regions outside the active side and cause confirmation changes in enzymes and make it inactive. Nevirapine and Delavirdine are currently available for clinical use. Doses: Nevirapine 200mg/day for 1 week then 200mg bid; Delavirdine 400mg tid.

C. Protease Inhibitors: These drugs are potent and

selective inhibitors of HIV1 protease enzymes. Saquinavir: It was first protease inhibitors Doses: 600mg qds. Ritonavir: Doses: Initially 300mg bid and can be increased to full dosage of 600mg bid. Indinavir: Doses: 800mg qds Nelfinavir: 750mg tid.

Stage 3. Early symtomatic disease: 1. Fever: Long term use of NS AIDS 2. Night sweats: Use of antipyratic agents 3. Chronic diarrhoea: Loperamid, Diphenoxylate HCl 4. Fatigue: Evaluate for thyroid or adrenal insufficiency, neuropathy, miopathy and treat if detective 5. Minor oral infections: treated with chlorohexidine 6. Headache: treatment with NSAIDS 7. Continue treatment with antiretroviral agents 8. Nutritional defc.: Iron, Vit. B12

Stage 4. Late Symptoma. 1. Continue treatment with antiretroviral agents 2. Continue treatment of symtomatic complaints Stage 5. Advance Disease these patients need more frequent clinical examination Diagnosis and Immediate treatment

Prophylactic Measures/ Universal Precautions

1.

a, b, c, d,

e,

In the out patient department any patient with open wounds should be examined with gloves eye protection with goggles should be done during flexible endoscopy use disposable instruments as much as possible reusable instruments like endoscopes are cleaned in soap and water and immersed in glutaraldehyde no surgical procedure involving sharp instrument is performed in OPD.

2. In the operating room

a, operating table is covered with a single sheet of polythene b, the number of theatre personnel is reduced to minimum c, the staff with abrasion or laceration on their hands are not allowed inside the theatre d, staff who entered the theatre should wear over shoes, gloves and disposable water resistant gowns and eye protection glasses.

E. Surgical Techniques: 1. 2.

3.
4. 5.

6.

Avoid sharp injury Prefer scissors or diathermy to the scalpal Use skin clips Avoid needle stick injuries Proper auto claving at the end of surgery AZT-Zidovudine, lamivudine and indinavir should be given for health workers falling exposures of susceptible areas to infected material from AIDS patients.

Rohit Sharma 69 pre-final year Department of Oral Medicine and Radiology