HIV and Acquired Immunodeficiency syndrome (AIDS

Learning Objectives
• The student should know. – Classification of HIV infection – Correlation between CD4 count and HIV associated diseases. – Importance of Viral load monitoring – Antiretroviral therapy and its side effects. HIV is a single stranded RNA retrovirus from Lentivirus family. After mucosal exposure, HIV is transported to lymph nodes via. dendritic, CD4 lymphocytes or Langerhan cells where infection becomes established. Free or cell associated virus is then disseminated widely through the blood with seeding of ‘sanctuary’ sites like CNS and latent CD4 cell reservoirs.

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Classification of HIV
• Primary infection – It is symptomatic in 70 – 80 % of cases and usually occurs 2-6 weeks after exposure. – Major clinical manifestations are • Fever with rash • Pharyngitis with cervical lymphadenopathy • Myalgia / Arthralgia • Headache • Mucosal ulceration – High plasma HIV-RNA levels and a fall in CD count up to 400 cells/mm3 Asymptomatic infection – Category A disease in the Centers for Disease Control (CDC) classification. – Follows and lasts for a variable period, during which the infected individual remains well with no evidence of disease except for possible presence of persistent generalized lymphadenopathy. – There is persistent viremia with decline in CD4 cells around 50 to 150 cells per year. Mildly symptomatic disease – CDC classification category B disease. – Develops in many indicating some impairment of cellular immunity but which is not AIDS defining.

– AIDS defining diseases • Esophgeal candidiasis • Cryptococcal meningitis • Chronic cryptosporidial diarrhea • Cerebral toxoplasmosis • CMV retinitis or colitis • Pneumocystis jirovecii pneumonia • • • • • • Disseminated Mycobacterium avium intracellulare Kaposi sarcoma Non-Hodgkin lymphoma Primary cerebral lymphoma HIV associated dementia HIV associated wasting Correlation between CD4 count and HIV associated diseases • >500 cells/mm3 • Acute primary infection • Recurrent vaginal candidiasis • Persistent generalized lymphadenopathy <500 cells/mm3 • Pulmonary tuberculosis • Pneumococcal pneumonia • Herpes zoster • Oropharyngeal candidiasis • Oral hairy leukoplakia • ITP • .– Clinical manifestations • Oral hairy leukoplakia • Recurrent oropharyngeal candidiasis. • Recurrent vaginal candidiasis • Severe pelvic inflammatory disease • • • • • • Bacillary angiomatosis Cervical dysplasia Idiopathic thrombocytopenic purpura Weight loss Chronic diarrhea Herpes zoster • Acquired Immunodeficiency Syndrome – CDC category C disease is defined by the development of specified opportunistic infections and tumors (AIDS defining lesions).

GI distress • Didanosine  Pancreatitis. hyperglycemia and elevated LFTs. – Protease Inhibitors • Hyperlipidemia. • When to start prophylactic medication.• • <200 cells/mm3 • Pneumocystis jirovecii pneumonia • Cryptosporidium • Microsporidium • Esophageal candidiasis • HIV associated wasting <100 cells/mm3 • Cerebral toxoplasmosis • Cryptococcal meningitis • Non-Hodgkin lymphoma • HIV associated dementia <50 cells/mm3 • CMV retinitis / colitis • Primary CNS lymphoma • Disseminated MAI CD4 count is also used for determining. hyperbilirubenemia . peripheral neuropathy • Stavudine Peripheral neuropathy. anemia. • Indinavir Nephrolithiasis. High viral load indicates a greater risk of complications of the disease. Antiretroviral Therapy • Currently available agents and their side effects. • • Viral Load Monitoring • • • Monitoring of viral load is the best method to monitor adequate response to therapy when patient is on anti retroviral medications. abnormal fat loss from face and extremities and redistribution in neck and back. peripheral neuropathy. These side effects are seen with all. Viral sensitivity is done to determine which antiretroviral medications will be effective in an individual patient. • Zalcitabine  Pancreatitis. – Nucleoside Reverse Transcriptase Inhibitors • Zidovudine  Leukopenia. • When to initiate antiretroviral medication. • Tenofovir is a nucleotide analog.

.• • Ritonavir  GI distress Nelfinavir  GI distress – Non-nucleoside Reverse Transcriptase Inhibitors. hepatotoxicity • Delavirdine Rash When to start therapy • Guidelines for starting are – CD4 < 350/microliter – Viral load (by PCR-RNA) >55000 What to start • • • Use two nucleosides combined with a protease inhibitor OR Use two nucleosides combined with efavirenz OR Use two nucleosides combined with two protease inhibitors. confusion and psychiatric problems • Nevirapine Rash. • These drugs are non competitive inhibitors of reverse transcriptase. • Efavirenz  Somnolence.

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