HIV infections and AIDS

DDS- 2
2017-18

Prepared by:
Prof. Dr. Myint Aung
MBBS, D. Bact.
M.Med.Sc. (Microbiology) Ph. D
Presented by:
Dr Deepa Anbazhagan April 27th , 2018
At the end of the lesson, the students should be
able to:
1. describe the structure of Human
immunodeficiency virus (HIV).
- RNA genome, reverse transcriptase
- envelope glycoproteins: gp120 and gp41
- core protein: p24
2. describe the modes of transmission of HIV
infection and AIDS.
3. discuss the pathogenesis of HIV infection
and AIDS.
4. describe the clinical manifestation of HIV infection and
AIDS.
- Primary HIV infection
- AIDS-related complex
- Full blown AIDS: opportunistic
infections and associated neoplasms
5. describe the laboratory and clinical diagnosis of HIV
infection and AIDS.
Laboratory diagnosis:
ELISA, Western Blot and other tests.
Clinical diagnosis:
Centers for disease Control (CDC) Classification
6. discuss the prevention of HIV infection and
AIDS
Aetiology of HIV/AIDS:
Causal organism = Human immunodeficiency
virus (HIV)
 HIV is a member of the genus Lentivirus and
Family Retroviridae.
 Lentiviruses have been isolated from many species,
including more than two dozen different African
nonhuman primate species.
 There are two distinct types of human AIDS viruses:
HIV-1 and HIV-2.
 The two types are distinguished on the basis of
genome organization and phylogenetic
(evolutionary) relationships with other primate
lentiviruses. 1/36
 Sequence divergence between HIV-1 and HIV-2
exceeds 50%.
 HIV in humans originated from cross-species
infections by simian viruses in rural Africa,
probably due to direct human contact with
infected primate blood.
 Current evidence is that the primate counterparts
of HIV-1 and HIV-2 were transmitted to humans
on multiple different occasions.
 HIV 1 infections are spreading worldwide.
 HIV 2 is more prevalent in Africa.
 HIV 2 produces a disease similar to but less
severe than AIDS. 2/36
Structure and composition of HIV:
 A complete HIV particle is spherical, 80-100 nm
in diameter and consists of:
- envelope
- capsid
- core
Envelope:
 Lipid bilayer derived from the host cell
membrane and contains some host proteins.
 The viral encoded glycoprotein gp 41
 Glycoprotein knob – gp120
 The gp 120 molecules bind to specific molecules
(CD4 receptors) on the surface of the host cell.
3/36
Capsid:
 Protein coat that surrounds the core of the virus
 Made up of p17 (matrix core protein)
 Cylindrical capsid

Core:
 Two identical molecules of linear single
stranded RNA (diploid).
 Structural proteins.
 Reverse transcriptase and other enzymes
 Main core protein (nucleocapsid core protein)
– p24. 4/36
HIV genome:
About 40% of the sequences of HIV-1 and HIV-2
are identical.
Structural genes of HIV
Envelope gene the envelope proteins
(env) (gp120, gp 41)
Group associated the core proteins
antigen gene (gag) (p 17, p 24, p 9)
Polymerase gene protease, endonucleases, integrase
(pol) and reverse transcriptase (RT)

5/36
Additional genes (regulatory gene)
are important in disease pathogenesis in vivo.
Tat transactivation of transcription gene
Rev regulator of expression of virion proteins
Vif viral infectivity factor
Vpu, vpx viral protein U,X
(promotes CD4 degradation)
(HIV- 1= Vpu, HIV- 2 = vpx)
Nef negative regulatory factor;
induces cytokine production by
macrophages – activate resting T cells.
Vpr viral protein R (increase transport of the
viral preintegration complex)
6/36
Based on env gene sequences:
 HIV-1 comprises three distinct virus groups
(M, N and O).
 the predominant M group contains
* at least ten subtypes or "clades" (A–J).
 HIV-2 comprises five subtypes (A–E).
 Within each subtype there is extensive
variability.

7/36
8/36
Disinfection and inactivation
 HIV is completely inactivated by treatment for 10
minutes at room temperature with any of the following:
- 10% household bleach
- 50% ethanol
- 0.5% Lysol
- 0.5% paraformaldehyde
- 0.3% hydrogen peroxide
# # undiluted bleach for at least 30 seconds
 The virus is also inactivated by extremes of pH (pH 1.0,
pH 13.0).
 heating at 56 °C for 10 minutes
 Lyophilized blood products 68 °C for 72 hours
9/36
 The illness was first described in 1981 and
HIV-1 was isolated by the end of 1983.
 Since then, AIDS has become a worldwide
epidemic.
 As of 2012, approximately 35.3 million people
are living with HIV globally.
 Of these, approximately 17.2 million are men,
16.8 million are women and 3.4 million are less
than 15 years old.
 There were about 1.8 million deaths from
AIDS in 2010.
 Sub-Saharan Africa is the region most affected.
10/36
Routes of transmission of HIV infection:
i) Sexual contact
ii) Parenteral exposure
iii) Vertical transmission
(from infected mother to child)

i) Sexual contact:
- heterosexual, homosexual, bisexual
- genital-oral sex with an infected partner.

11/36
ii) Parenteral exposure
- transfusion of infectious or contaminated blood
and blood products.
- intravenous drug users infected through the use
of contaminated syringes and needles.
- Health-care personals through needle stick
injury with contaminated blood.
iii) Vertical transmission
- from infected mother to child
* prenatal through placental circulation
* perinatal through mother’s birth canal
* post natal through mother’s breast milk
12/36
Rare circumstances but there has no evidence of
virus transmission:
i) Casual contact with HIV-infected person
ii) Insect vectors 13/36
Pathogenesis:
 Stages of infection include:
- the primary infection
- dissemination of virus to lymphoid organs
- clinical latency
- elevated HIV expression
- clinical disease and death.
 The duration between primary infection and
progression to clinical disease averages about 10
years.
 In untreated cases, death usually occurs within 2
years after the onset of clinical symptoms.

14/36
 Following primary infection, there is a 4 to
11days period between mucosal infection and
initial viraemia; the viraemia is detectable for
about 8-12 weeks.
 Virus is widely disseminated throughout the
body during this time and the lymphoid organs
become seeded.
 An acute mononucleosis-like syndrome
develops in many patients (50-75%) 3-6 weeks
after primary infection.
 There is a significant drop in numbers of
circulating CD4 T cells at this early time.
15/36
 An immune response to HIV occurs 1 week to
3 months after infection, plasma viraemia
drops and levels of CD4 cells rebound.
 However, the immune response is unable to
clear the infection completely and HIV-
infected cells persist in the lymph nodes.
 This period of clinical latency may last for as
long as 10 years.

16/36
 During this time, there is a high level of ongoing
viral replication. It is estimated that 10 billion HIV
particles are produced and destroyed each day.
 CD4 T lymphocytes, major targets responsible for
virus production, appear to have similar high
turnover rates.
 Because of this rapid viral proliferation and the
inherent error rate of the HIV reverse
transcriptase, it is estimated that every nucleotide
of the HIV genome probably mutates on a daily
basis.

17/36
 Eventually, the patient will develop
constitutional symptoms and clinically
apparent disease, such as opportunistic
infections or neoplasms.
 Higher levels of virus are readily detectable in
the plasma during the advanced stages of
infection (AIDS).
 HIV found in patients with late-stage disease
is usually much more virulent and cytopathic
than the strains of virus found early in
infection.
18/36
 19/36

Typical course of untreated HIV infection .

The prognosis of the infection is assessed by measuring
the viral load and CD4 count in patient’s serum/blood.
CD4 T Lymphocytes, Memory Cells and latency:
• The CD4 molecule is the major receptor for
HIV; it has a high affinity for the viral envelope.
• The HIV coreceptor on lymphocytes is the
CXCR4 chemokine receptor.
• The cardinal feature of HIV infection is the
depletion of T helper-inducer lymphocytes due
to:
- the result of HIV replication in this
population of lymphocytes
- the death of uninfected T cells by indirect
mechanisms. 20/36
• Early in infection, primary HIV isolates are
monocyte or macrophage-tropic (M-tropic).
• As the infection progresses, the dominant M-tropic
viruses are replaced by T-tropic viruses.
• The consequences of CD4 T cell dysfunction
caused by HIV infection are devastating because
the CD4 T lymphocyte plays a critical role in the
human immune response.
• Many infected T cells are killed, but a fraction
survive and revert to a resting memory state.
• There is little or no virus gene expression in the
memory cells and they provide a long-term, stable
latent reservoir for the virus. 21/36
• When exposed to antigen or when drug
therapy is discontinued, the memory cells
become activated and release infectious virus.
Monocytes and Macrophages:
 Monocytes and macrophages play a major
role in the dissemination and pathogenesis of
HIV infection.
 Certain subsets of monocytes express the
CD4 surface antigen and therefore bind to the
envelope of HIV.
 The HIV coreceptor on monocytes and
macrophages is the CCR5 chemokine
receptor. 22/36
 Macrophage-tropic strains of HIV predominate early
after infection and these strains are responsible for
initial infections even when the transmitting source
contains both M-tropic and T-tropic viruses.
 It is believed that monocytes and macrophages serve
as major reservoirs for HIV in the body.
 In the brain, the major cell types infected with HIV
appear to be the monocytes and macrophages.
 This may have important consequences for the
development of neuropsychiatric manifestations
associated with HIV infection.
 Infected pulmonary alveolar macrophages may play
a role in the interstitial pneumonitis seen in certain
patients with AIDS. 23/36
Lymphoid Organs:
• Lymphoid organs play a central role in HIV infection.
• Throughout the course of untreated infection—even
during the stage of clinical latency—HIV is actively
replicating in lymphoid tissues.
• The microenvironment of the lymph node is ideal for
the establishment and spread of HIV infection.
Neural Cells:
 Virus may enter the brain through infected
monocytes and release cytokines that are toxic to
neurons as well as chemotactic factors that lead to
infiltration of the brain with inflammatory cells.
 HIV is present rarely, if at all, in neurons,
oligodendrocytes and astrocytes. 24/36
Opportunistic infections:
The damaging effects of HIV on the immune system
leaves patients vulnerable to many types of infections.
(1) Bacteria: Mycobacterium avium-intracellulare,
Mycobacterium tuberculosis, Listeria monocytogenes,
Nocardia asteroides, Salmonella spp., Streptococcus spp.
(2) Viruses: Cytomegalovirus, herpes simplex virus,
varicella-zoster virus, adenovirus, polyomavirus, JC
virus, hepatitis B virus, hepatitis C virus.
(3) Fungi: Candida albicans, Cryptococcus neoformans,
Coccidioides immitis, Histoplasma capsulatum,
Pneumocystis jiroveci.
(4) Protozoa: Toxoplasma gondii, Isospora belli,
Cryptosporidium spp.
25/36
Cancer:
• AIDS patients exhibit a marked predisposition to
the development of cancer, another consequence
of immune suppression.
• AIDS-associated cancers include non-Hodgkin's
lymphoma (Polyomavirus SV40), Kaposi's
sarcoma, cervical cancer and anogenital cancers.
• EB viral DNA is found in the majority of B cell
malignancies classified as Burkitt's lymphoma.
• Other HIV-associated malignancies include head
and neck cancer, lung cancer, Hodgkin
lymphoma, liver cancer, melanoma and oral
cancer. 26/36
Clinical manifestations:
Symptoms of acute HIV infection are nonspecific
and include fatigue, rash, headache, nausea and night
sweats.
AIDS is characterized by pronounced
suppression of the immune system and
development of a wide variety of severe
opportunistic infections or unusual neoplasms
(especially Kaposi's sarcoma).
According to the US CDC definition,
One has AIDS, if he/she is infected with HIV and present with:
- A CD4+ T-cell count below 200 cells/µl
- or he/she has one of the defining illnesses
(opportunistic infections and or cancers). 27/36
Laboratory Diagnosis:
• Evidence of infection by HIV can be detected
in three ways:
(1) virus isolation
(2) serologic determination of antiviral
antibodies
(3) measurement of viral nucleic acid or
antigens.

28/36
Virus Isolation
• HIV can be cultured from lymphocytes in peripheral
blood (and occasionally from specimens from other
sites).
• The most sensitive virus isolation technique is to
cocultivate the test sample with uninfected, mitogen-
stimulated peripheral blood mononuclear cells.
• Viral growth is detected by testing culture
supernatant fluids after about 7-14 days for viral
reverse transcriptase activity or for virus-specific
antigens (p24).
• Virus isolation techniques are time-consuming and
laborious and are limited to research studies.
Serology
• Test kits are commercially available for
measuring antibodies by enzyme-linked
immunoassay (ELISA /EIA).
• When EIA-based antibody tests are used for
screening populations with a low prevalence
of HIV infections (eg, blood donors), a
positive test in a serum sample must be
confirmed by a repeat test.
• If the repeat EIA test is reactive, a
confirmation test is performed to rule out
false-positive EIA results.
30/36
• The most widely used
confirmation assay is the
Western blot technique, in
which antibodies to HIV
proteins of specific molecular
weights can be detected.
• Antibodies to viral core
protein p24 or envelope
glycoproteins gp41, gp120 or
gp160 are most commonly
detected.
• The response pattern against
specific viral antigens
changes over time as patients
progress to AIDS.

31/36
• The simple tests (rapid tests)can be performed on
blood or oral fluid and are based on principles such
as particle agglutination or immunodot reactions.
• The mean time to seroconversion after HIV
infection is 3-4 weeks.
• Most individuals will have detectable antibodies
within 6-12 weeks after infection.

32/36
Detection of Viral Nucleic Acid or Antigens
• Amplification assays such as the RT-PCR,
DNA PCR, and bDNA tests are commonly
used to detect viral RNA in clinical specimens.
• The antigen often becomes undetectable after
antibodies develop but may reappear late in
the course of infection, indicating a poor
prognosis.
• The HIV RNA levels (viral load) are important
predictive markers of disease progression and
valuable tools with which to monitor the
effectiveness of antiviral therapies. 33/36
In management, monotherapy usually results in
the rapid emergence of the drug-resistant
mutants of HIV.

Combinations of antiretroviral drugs

Highly Active Antiretroviral Therapy (HAART):
- suppress viral replication to below limits of

detection in plasma
- However, HAART has failed to cure HIV-1
infections.
34/36
Prevention and control:
1) There has no drug or vaccine for prevention.
2) Infected persons should refrain from donating
blood, plasma, body organs, other tissues or
sperm.
3) Do not share unsterile needles or syringes.
4) Toothbrushes, razors and other implements
that could become contaminated with blood
should not be shared.
5) After accidents that result in bleeding,
contaminated surfaces should be cleaned with
household bleach freshly diluted 1:10 in water.
35/36
6) Any extramarital sexual intercourse should be
protected by a condom.
7) All women, who have been potentially exposed
should seek HIV antibody testing before
becoming pregnant. If the test is positive, should
consider avoiding pregnancy.
8) HIV-infected mothers should avoid breast
feeding to reduce transmission of the
virus to their children if safe alternative
feeding options are available.
9) World AIDS day = 1st December of every year.
36/36
Reference:
1) Jawetz, Melnick & Adelberg’s Medical
Microbiology (27th. Ed.) (2016). Lange
2) Richard V. Goering, Hazal M. Dockrell, Mark

Zuckerman, Ivan M. Roitt, Peter L. Chiodini

“ Mims’ Medical Microbiology” (5th. Ed.)
(2013). Elsevier Saunders