HIV / AIDS

H - Human
I - Immunodeficiency
V - Virus
Aids A.I.D.S

A - Acuired
I - Immuno
D - Deficiency
S - Syndromme
History

1981 First discovered in USA by

Gotlab in Homosexuals
1983 Luc Montagnier isolated virus
from Lymph Nodes
1986 First case in India from
Madras from a CSW
1987 First case in A.P – in
Hyderabad – dies in fever hos
The Global
HIV/AIDS Epidemic
• Global pandemic – HIV/AIDS found
throughout the world, in every region

• Earlier projections surpassed. HIV/AIDS on

track to be the worst epidemic in history

• We may still be in the epidemic’s early

phase

• HIV/AIDS is really multiple epidemics

(different populations, levels, regions)
• Certain populations at particular risk – youth,
women, men who have sex with men,
injection drug users – but generalized
epidemic in many countries

• Hardest hit countries are least equipped to

respond

• Multi-sectoral impact, “collateral” effects:

development and economic growth,
education, food supply, communities,
households, and individuals

• We know a lot and very little…

 Current Global Estimates
• 39.4 million estimated to be living with HIV/AIDS worldwide

• 4.9 million new infections in 2004 (almost 14,000 each day)

• 3.1 million deaths in 2004 (more than 8,000 deaths per day)

• Most people with HIV/AIDS (95%) reside in low and middle

income countries, where most AIDS-related deaths occur

• HIV is now the leading cause of death worldwide among those

ages 15-59
People Estimated to be Living with
HIV/AIDS, Global Totals, 1981-2004
40,000,000 End 2004:
39.4 million

30,000,000

20,000,000

10,000,000

0
‘81 ‘84 ‘86 ‘88 ’90 ‘92 ‘94 ‘96 ‘98 ‘00 ‘02 ‘04
Years
Sources: UNAIDS, AIDS Epidemic Update, December 2004; UNAIDS, Data
Request, November 2004.
People Living with HIV/AIDS by Region,
as Percent of Global Total, end of 2004
Sub-Saharan Africa

South/South-East Asia 18%

Latin America 4%
Eurasia 4%
North America 3%
East Asia 3%
Western Europe 2%

North Africa/Middle East 1% Total = 39.4 million

Caribbean 1%
Oceania < 1%

Source: UNAIDS, AIDS Epidemic Update, December 2004.

 Almost Two-Thirds of all People Living with
HIV/AIDS are in Sub-Saharan Africa

Percent of Prevalence

Sub-Saharan In 2004:
Africa •63% of new infections
64%
•74% of deaths
Rest of
World •South Africa – highest
36% number of people living
with HIV/AIDS (5.3m)

N = 39.4 Million

Source: UNAIDS, 2004 Report on the Global AIDS Epidemic, July 2004; UNAIDS, AIDS
Epidemic Update, December 2004.
HIV Virus
Scientists at the University of Pennsylvania have developed a
genetically-engineered strain of the AIDS virus that combats

other, more deadly strains.

Doctors in the US first reported a new
disease, AIDS (acquired immune
deficiency syndrome), in 1981. It has
since become a world wide epidemic.
AIDS is caused by the human
immunodeficiency virus (HIV), which
attacks the immune system, disarming
the body's defences against infections
and certain cancers. Germs that cause
minor illnesses in healthy people can
make people with AIDS very ill.
• HIV attacks and kills crucial immune
system cells, known as T-helper cells.
Without T-helper cells, which kill cells that
have been infected with germs, many other
immune system cells cannot not work
properly, including B-cells that make
antibodies. A person infected with HIV may
not show any symptoms for years. But
untreated, the number of T-helper cells
steadily drops. Eventually, the numbers fall
so low that the risk of infection greatly
increases, and the symptoms of AIDS
appear.
Patient Clinical Presentation,
Differential Diagnosis and
Follow-Up

Part A: Module A1
Session 7
Objectives

1. Identify common disorders associated with HIV

infection
2. Diagnose HIV infection based on major
and minor signs and symptoms when
CD4 cell counts are not available
3. Diagnose HIV infection based on WHO
laboratory and clinical classification
systems
4. List diseases that have a presentation
similar to HIV
 Objectives, continued

5. Discuss the importance of

testing for HIV when testing
for these other diseases
6. Give examples of factors that
help in making a diagnosis
7. Discuss follow-up procedures
in their local situation
Outline of Session

A. Patient Clinical Presentation

1. Introduction
2. WHO case definitions for HIV/AIDS
surveillance in countries with limited
clinical and laboratory diagnostic
facilities

B. Differential Diagnosis and Follow-Up

1. Differential diagnosis
2. Follow-up visits
Patient Clinical Presentation
Introduction
• Diagnosing and staging HIV disease in a
person living in a resource limited country
is not done easily or quickly
• A good clinical examination and thorough
interview of the patient is needed
• WHO AIDS case definition and staging
system is useful –it has been adapted for
countries with limited clinical and
laboratory diagnostic facilities
• A further refinement of the WHO staging
system is also proposed for settings where
laboratory monitoring is not available
WHO Case Definitions
Where HIV testing is not available, patients can be
diagnosed clinically based on major and minor signs
and symptoms
• Case definition for HIV/AIDS is
fulfilled in the presence of at least 2
major signs and at least 1 minor sign:
• Major signs (weight loss, chronic
diarrhea, prolonged fever)
• Minor signs (persistent cough, herpes
zoster, oropharyngeal candidiasis, etc.)

The problem with this method is its low sensitivity and specificity
WHO Case Definitions

Where HIV testing is available

• The case definition for HIV/AIDS is fulfilled if
an HIV test is positive and one or more of
the following conditions is present:
• Weight loss • HIV encephalopathy
• Cryptococcal meningitis • Esophageal candidiasis
• Tuberculosis • Life threatening or
• Kaposi’s sarcoma recurrent pneumonia
• Invasive cervical cancer
WHO Clinical Staging
System

• The WHO clinical staging system includes:

• a clinical classification system
• a laboratory classification to categorize the
immunosuppression of adults by their total
lymphocyte counts

• This staging system has proven reliable for

predicting morbidity and mortality in infected
adults
• The WHO Clinical Staging System is based
on clinical markers believed to have
prognostic significance resulting in four
categories
WHO Clinical Staging
System
Clinical Stage 1
1. Asymptomatic infection
2. Persistent generalized lymphadenopathy
(PGL)
3. Acute retroviral infection
Clinical Stage 2
4. Unintentional weight loss, < 10%
5. Minor mucocutaneous manifestations
6. Herpes zoster, within previous 5 years
7. Recurrent upper respiratory tract infections
WHO Clinical Staging
System
Clinical Stage 3

12. Oral hairy leukoplakia

8.Unintentional 13. Pulmonary tuberculosis
weight loss, 14. Severe bacterial
>10% infections
9.Chronic diarrhea
15. Vulvovaginal
10.Prolonged fever candidiasis
11.Oral candidiasis
 WHO Clinical Staging
System
Clinical 24. PML (progressive
Stage 4 multifocal
16. HIV wasting syndrome leukoencephalopathy)
17. PCP 25. Any disseminated
18. Toxoplasma of the brain endemic mycosis
19. Cryptosporidiosis with 26. Candidiasis of the
diarrhea esophagus, trachea,
bronchi, and lungs
20. Isosporiasis with diarrhea
21. Extrapulmonary 27. Atypical mycobacteriosis
cryptococcosis 28. Non-typhoid Salmonella
22. Cytopmegaloviral disease of septicemia
an organ other than 29. Extrapulmonary TB
liver,spleen, or lymph node 30. Lymphoma
23. Herpes simplex virus 31. Kaposi’s sarcoma
infection
32. HIV encephalopathy
 WHO Clinical Staging
System
• WHO Improved Clinical Staging
System: A further refinement of the
WHO clinical staging system
includes a laboratory axis. The
laboratory axis subdivides each
category into 3 strata (ABC)
depending
Laboratory axis on the number of CD4
Clinical axis
cells.
Lymphocytes* If**thisStage
CD4 is 1not available,
Stage 2 Stagetotal
3 Stage 4
lymphocytes can beEarly
Asymptomatic usedIntermediate
as an Late
PGL HIV (ARC)*** AIDS
A
alternative marker 3A
>2000 >500 1A 2A 4A
B 1000- 2000 200- 1B 2B 3B 4B
500
C <1000 <200 1C 2C 3C 4C
Case Study
Differential Diagnosis
and Follow-Up
Differential Diagnosis

• Initial diagnosis of HIV may be difficult

 The more general signs and symptoms of HIV
are common to many infections
 Patients may have acquired both HIV and
other sexually transmitted or blood-borne
diseases at the same time
 It is important to consider HIV testing when
testing for other infections that have similar
presentation
Differential Diagnosis

• The following diseases have a similar

presentation:

•• Viral hepatitis
Epstein-Barr virus mononucleosis
•• Primary herpes simplex
Cytomegalovirus virus infection
mononucleosis
•• Disseminated gonococcal infection
Toxoplasmosis
•• Other viral infections
Rubella
• Syphilis
Differential Diagnosis
Examples of differentiating factors
Epstein-Barr virus mononucleosis
Factor EBV infection HIV infection
Onset Insidious Acute
Tonsillar hypertrophy Common Mild enlargement
Exudative pharyngitis Common Rare
Skin rash Rare Common
Mucocutaneous ulcers Rare Common

Jaundice Occurs in 8% Rare

Diarrhea Unknown Occurs
Atypical lymphocytes Occurs in 80-90% Occurs <50%
Differential Diagnosis
Ulcers
HIV infection
Mucocutaneous ulceration is a
distinctive feature and has
been reported on the buccal
mucosa, gingival, palate,
esophagus, anus, and penis.
Ulcers are generally small,
round or oval and surrounding
mucosa usually looks normal.
Other infections
Such ulceration is
uncommon in most
conditions that constitute the
differential diagnosis.
 
Only primary herpes may
present with similar ulcers.
Differential Diagnosis
Rash
HIV infection Other infections
An erythematous, non- Skin rashes are not a feature
pruritic, maculopapular rash of infectious mononucleosis,
is common during primary toxoplasmosis, or
HIV infection. cytomegalovirus infection.
 
Generally symmetrical. May  
become generalized, with  
lesions 5-10 mm in diameter.  
  Rashes involving the palms
The face or trunk is usually and soles are rare in most
affected, but extremities, viral infections.
including the palms and
soles, can also be involved.
Differential Diagnosis

• Laboratory tests can be used to

determine the diagnosis
(See Session 6 in Part A Module A1)
Follow-Up Visits
• It is important that a system of referrals be accessed and
that the clinician does not fall into three common errors of
thinking —
• After being informed about their results, patients may need
closer follow-up (weekly or monthly) for psychological
support and informational needs
(1) that they must provide for all of the patient’s needs
(2) that the patient only needs what they can provide
(3) that follow-up means care for acute problems only
• Once the relationship is established and the patient
understands his/her situation and the condition is stable,
the interval may be extended to every 3 months
Follow-Up Visits, continued

• Should include the following

tests:
• Complete blood count every 3
months
• CD4 cell count or lymphocytes
every 6 months
• Other examinations according to
symptoms