1. HIV & AIDS – SOME REFLECTIONS
Dr Ratnadeep Ganguly
MD,DNB,MNAMS,MIAC
Dept of Pathology
Dr Debkant Pradhan
MD(Microbiology)
Dept of Microbiology
THE MISSION HOSPITAL,
DURGAPUR

2. H Human
I Immunodeficiency
V Virus

3. A Acquired
I Immuno
D Deficiency
S Syndrome

5. Status of HIV epidemic in India, 2000

6. HIV Transmission
 HIV enters the bloodstream through:
 Open Cuts
 Breaks in the skin
 Mucous membranes
 Direct injection

7. HIV Transmission
 Common fluids that are a means of transmission:
 Blood
 Semen
 Vaginal Secretions
 Breast Milk

8. HIV in Body Fluids
Semen
11,000 Vaginal
Fluid
7,000
Blood
18,000
Amniotic
Fluid
4,000 Saliva
1
Average number of HIV particles in 1 ml of these body fluids

9. Routes of Transmission of HIV
Sexual Contact: Male-to-male
Male-to-female or vice versa
Female-to-female
Blood Exposure: Intravenous drug use/needle sharing
Occupational (needle stick injuries)
Transfusion of blood products
Perinatal: Transmission from mother to baby
Breastfeeding

10. HIV-Infected T-Cell
HIV
Virus
T-Cell
HIV Infected
T-Cell
New HIV
Virus

11. Window Period
 This is the period of time after becoming
infected when an HIV test is negative
 90 percent of cases test positive within three
months of exposure
 10 percent of cases test positive within three to
six months of exposure

12. HIV Infection and Antibody Response
6 month ~ Years ~ Years ~ Years ~ Years
Virus
Antibody
Infection
Occurs
AIDS Symptoms
---Initial Stage---- ---------------Intermediate or Latent Stage-------------- ---Illness Stage---
Flu-like Symptoms
Or
No Symptoms
Symptom-free
<
----
----

13. Importance of Early Testing
and Diagnosis
 Allows for early treatment to maintain and
stabilize the immune system response
 Decreases risk of HIV transmission from
mother to newborn baby
 Allows for risk reduction education to reduce
or eliminate high-risk behavior

14. HIV Testing
 Those recently exposed should be retested at least
six months after their last exposure
 Screening test (EIA/ELISA) vs. confirmatory test
(IFA / Western blot)
EIA/ELISA (Reactive)
Repeat EIA/ELISA (Reactive)
Western blot
Positive for HIV

15. EIA/ELISA
Test
PositiveNegative
Run IFA
Confirmation
Repeat
Positive
Positive
End Testing
Repeat ELISA
Every 3 months
for 1 year
Negative
PositiveNegativeIndeterminate
Repeat at
2-4 months
Repeat at
3 weeks
HIV Testing
No HIV Exposure
Low Risk
HIV Exposure
High Risk
Negative
HIV
+
Repeat every
6 months for continued
High risk behavior
No HIV Exposure
Low Risk
HIV Exposure
High Risk

16.  Once a person is infected they are always
infected
 Medications are available to prolong life but
they do not cure the disease
 Those who are infected are capable of
infecting others without having symptoms or
knowing of the infection
HIV AIDS

17. HIV Risk Reduction
 Avoid unprotected sexual contact
 Use barriers such as condoms and dental
dams
 Limit multiple partners by maintaining a
long-term relationship with one person
 Talk to your partner about being tested
before you begin a sexual relationship

18. HIV Risk Reduction
 Avoid drug and alcohol use to maintain good
judgment
 Don’t share needles used by others for:
Drugs
Tattoos
Body piercing
 Avoid accidental exposure to blood products

19. People Infected with HIV
 Can look healthy
 Can be unaware of their infection
 Can live long productive lives when
their HIV infection is managed
 Can infect people when they engage in
high-risk behavior

20. HIV Exposure and Infection
 Some people have had multiple
exposures without becoming infected
 Some people have been exposed one time
and become infected

21. “When you have sex with
someone, you are having sex with
everyone they have had sex with
for the last ten years.”
Former Surgeon General
C. Everett Koop

22. HIV and Sexually
Transmitted Diseases

23. HIV and Sexually
Transmitted Diseases
STDs increase infectivity of HIV
 A person co-infected with an STD and HIV may
be more likely to transmit HIV due to an increase
in HIV viral shedding
 More white blood cells, some carrying HIV, may
be present in the mucosa of the genital area due to
a sexually transmitted infection

24. HIV and Sexually
Transmitted Diseases
 STDs increase the susceptibility to HIV
 Ulcerative and inflammatory STDs compromise
the mucosal or cutaneous surfaces of the genital
tract that normally act as a barrier against HIV
 Ulcerative STDs include: syphilis, chancroid,
and genital herpes
 Inflammatory STDs include: chlamydia,
gonorrhea, and trichomoniasis

25. HIV and Sexually
Transmitted Diseases
 The effect of HIV infection on the immune
system increases the risk of STDs
A suppressed immune response due to HIV
can:
 Increase the reactivation of genital ulcers
 Increase the rate of abnormal cell growth
 Increase the difficulty in curing reactivated or
newly acquired genital ulcers
 Increase the risk of becoming infected with
additional STDs

26. Laboratory Tests
( Diagnosis / disease progression )
 Tests that detect antibody
 Tests that detect antigen
 Tests that detect viral nucleic acid
 Tests to estimate CD 4+ve T – cells

27. IMMUNE RESPONSE

28. Antibody Detection
 most widely used
 most effective way
 Tests divided into two broad groups
 Screening assays-
 designed to detect all infected samples / individuals
 high sensitivity
 Supplemental assays / confirmatory tests
 designed to identify samples or individuals with
positive screening tests
 high specificity

29. Internal
control
HIV 2
gp36
HIV 1
gp41
gp120
Rapid Test
Defined as a test with a total reaction time of 30
minutes or less

30. Simple Test
 Requires a reaction time of less than 30 minutes
 requires no special instrumentation
 can be performed easily
 Tests available
 passive haemagglutination test ( PHA )
 latex agglutination test ( LAT )
 gelatin particle agglutination test ( PAT )

31. Supplemental Tests
 Recommended for validation of positive results on
screening tests
 Western Blot assay ( WB )
 Immunofluorescence assay ( IFA )
 Line immunoassay ( LIA )

32. Western Blot Assay

33. Immuno-fluorescence assay
Direct Indirect
Antigen
Primary
antibody
Fluorescent
dye
Secondarya
antibody

34.  Conventional ELISA- sensitivity 50 - 60 pg / mL
 Immune-complex dissociated ELISA
-preliminary acid hydrolysis-sensitivity 10 pg / mL
Indications Limitations
 Window period 30 %
 AIDS 50-60 %
 ARC 30-40 %
 Newborns / infants 20 %
 Asymptomatic 10 %
Detection of HIV antigen ( p24 Ag )

35. Detection of Viral Nucleic acid
Template Procedure
 Viral RNA in plasma RT - PCR
 Viral RNA cell associated RT - PCR
 Integrated proviral DNA PCR

36. Quantification of Viral Load
 Quantitation invaluable towards study of
 prognostic marker early in disease
 Three techniques used
 RT - PCR
 NASBA
 b DNA

37. Sensitivity
 Thermo labile- inactivated at 600C-10 min
1000C- sec
 Withstand lyophilisation
 Inactivated by : Absolute ethanol
: 4 % Formaldehyde
: 6 % Hydrogen peroxide
: 2 % Glutaraldehyde
: Concentrated Bleach
: 0.5 – 2 % Hypo chlorite
 In room temp survival :7 days

38. Predictors of Disease Progression
Serial
No
Clinical
Condition
Risk of developing
AIDS over 18-24
months
1. Early stage (CD4
>500/uL)
< 5%
2. Intermediate(CD4
200-500/ul)
20-30 %
3. Late (CD4 50-200/
uL)
50-70%
4. Advanced ( CD4 <10/
uL) on HAART
Survival 5-7 years.

39. HIV Post Exposure
Prophylaxis

40. HIV Occupational Exposure
 Review facility policy and report the incident
 Medical follow-up is necessary to determine the
exposure risk and course of treatment
 Baseline and follow-up HIV testing
 Four week course of medication initiated one to
two hours after exposure
 Liver function tests to monitor medication
tolerance
 Exposure precautions practiced

41. HIV Non-Occupational Exposure
 No data exists on the efficacy of antiretroviral
medication after non-occupational exposures
 The health care provider and patient may decide
to use antiretroviral therapy after weighing the
risks and benefits
 Antiretrovirals should not be used for those with
low-risk transmissions or more than 72 hours after
exposure
PREVENTION --- FIRST

42. HAART – Highly active anti retroviral
treatment
 Nucleoside and nucleotide reverse transcriptase inhibitors (nRTI)
 Non-nucleoside reverse transcriptase inhibitors (NNRTI)
 Protease inhibitors (PIs)
 Integrase inhibitors
 Entry inhibitors (or fusion inhibitors)
 Maturation inhibitors
 Broad spectrum inhibitors
Combination therapy based on clinical stage of disease and CD 4 count

43. Treatment, care & support programs -
Background
The purpose of HIV/AIDS care, treatment and support
programs is:
 To assure equitable access to diagnosis, medical
care, pharmaceuticals and supportive services
 To reduce morbidity and mortality from
HIV/AIDS complications
 To promote prevention opportunities within care
and support service delivery
 To improve the quality of life of both adults and
children living with HIV/AIDS and their
families

44. Components of Comprehensive Care,
Treatment and Support
 Medical and nursing care
 Psychological support
 Socioeconomic support
 Involvement of HIV positive individuals
and their families
 Respecting human rights and meeting legal
needs

45. Medical and Nursing Care
 Counseling and testing
 Prophylaxis of
opportunistic infections
(OIs)
 Management of HIV-
related illnesses, including
OIs
 TB control
 STI management
 Management of HIV
disease
 Palliative care
 Access to HIV-related
drugs
 Interventions to reduce
parent-to-child
transmission
 Clinical HIV/AIDS care
for mothers and infants
 Support systems such as
functional laboratories
and drug management
systems
 Nutritional support
 Health education
 Adequate universal
precautions

46. Psychological Support
 Community services to meet the emotional and
spiritual needs of HIV-positive individuals and
their families, including support through post-test
clubs and peers

47. Socioeconomic Support
 Material and social support within communities
to ensure nutritional and daily living needs are
met
 Support for orphans and vulnerable children
(OVC)

48. Involvement of Individuals and
Families
 Involvement of HIV-positive individuals and
their families in service planning and delivery to
ensure that HIV care and support programs
intended for them address their needs and
include human rights

49. Respecting Human Rights and
Meeting Legal Needs
 Services that address stigma and discrimination
issues in health facilities, in communities and in
the workplace and that promote equal access to
care

50. Human Rights & Legal Support
stigma & discrimination reduction
succession planning
PLHA participation
Clinical Care (medical & nursing)
VCT , PMTCT
preventive therapy (OIs, TB)
management of STIs and OIs
palliative care, nutritional support
antiretroviral therapy
Socioeconomic Support
material support
economic security
food security
Psychosocial Support
counseling
orphan care
community support services
spiritual support
Comprehensive HIV/AIDS Care and Support
Adults and Children
Affected by
HIV/AIDS
r
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51. Continuum of HIV/AIDS Care and
Treatment

52. Principles of
Chronic Disease Management
 Requires patient and health providers to work as a
team
 Demands consistent relationship between patient
and health-care team members
 Requires regular interdisciplinary care team
meetings to discuss care issues, review treatment
protocols, express concerns and support
colleagues

53. Standards of Care
The purpose of setting standards of care is:
• To promote delivery of the highest possible
quality of care
• To establish measures for evaluating and
improving client services
This requires:
• Deciding how to achieve standards
• Applying them in clinical practice
• Evaluating to see if they have been achieved

54. Clinical services include affordable and standardized
practices based on international and national
guidelines:
• Preventive therapies
• Management of HIV-
related conditions and
opportunistic infections
• Laboratory services
• Secure supply of
prescribed medications
• Antiretroviral therapy
(ART)
• Post-exposure prophylaxis
(PEP) for occupational
injuries and rape
• STI management
• Palliative care
Standards of Care, continued

55. Prevention as Part of Care and
Treatment
Targets of opportunity for integrating
prevention into care and treatment:
• Clinic waiting room: posters, videos, brochures
and condoms
• Provider-patient interaction: provider should
remind clients about prevention of HIV
transmission—ABCs
• Home care: visitors to the homes of can carry
condoms and talk about proper precautions

56. from
The Mission Hospital
Institute of Laboratory
Medicine team