HIV/AIDS/OPPORTUNISTIC

INFECTION

24 Years of HIV/AIDS
1981 Unusual immune deficiency identified
among previously healthy gay men in
US
1982 Acquired Immune Deficiency
1983 HIV virus identified as cause of AIDS
1987 First therapy for AIDS AZT
1996 Concept of HAART
HAART (highly active antiretroviral therapy)

HIV INFECTION

Dynamics of HIV Transmission

Risk Group
Population

General Population

General
Population

Bridge
Population

Structure of HIV
Surface
proteins
gp 120, gp
41

Lipid
Membrane
outer
surface

Reverse
transcriptase
enzyme in
life cycle

Live cycle of HIV

http://www.medscape.com/viewarticle/506280_1

HIV entry into the body

HIV Lifecycle

Host cells infected with HIV have a very short

lifespan.
HIV continuously uses new host cells to replicate
itself.
Up to 10 million individual viruses are produced
daily.
During the first 24 hours after exposure, the virus
attacks or is captured by dendritic cells (type of
phagocyte) in mucous membranes and skin.
Within five days of exposure, infected cells make
their way to lymph nodes and then to the
peripheral blood, where viral replication becomes
very rapid.

HIV Lifecycle
Phases: binding and entry, reverse transcription,
replication, budding, and maturation
Reverse
Transcriptions
Act Here

6. Release

Protein
Inhibitors
Act Here

3. Transcription

1. Attachment

7. Maturation

2. Entry
4. Integration

5. Polyprotein
Production

10

How HIV Infects the Body

11

Virus destroys the cell as a result of

budding
But few cells are infected:
Early stage of infection 1:10,000
Late 1:40
HIV could kill sub population of precursor
cells
People develop AIDS even when they have
HIV that does not lyze cells

1. PUNCTURED
MEMBRANE

Why do all T4
cells
disappear?12

Relating Disease Progression to HIV1 RNA Level and CD4 Cell Count
Viral Load
1,000

100
10,000

200
100,000

300

400
1000

900

800

700

600

500

CD4 COUNT
+

Adapted with permission from Coffin. AIDS. 1996;10(suppl 3):S75-S84.

13

Progression of HIV
disease
Asymptomatic HIV (clinical latency)
Patient often unaware of infection
Immune system able to control virus to limited extent
Able to transmit HIV to others

Symptomatic HIV
Minor to moderately severe symptoms
Recurrent symptoms

AIDS
Severe immunosuppression associated with
opportunistic infections or cancers

Without antiretroviral treatment

30% will develop AIDS in 3 years
90% will develop AIDS within 10 years
14

HIV and AIDS

15

CLINICAL MANIFESTATIONS

16

CLINICAL STAGES OF HIV

INFECTION
Generalised
Lymphadenopath
y Fever, Weight
loss

Fever, Rash,
Arthralgia,
LNE
2- 6 wks

Opportunistic
Infection
Malignant
diseases

Incubation Period

Primary
Infection

Asymptomat
ic
Period

Pre AIDS
syndrom
e

AIDS

Acquisition of virus
LNE: Lymph Node Enlargement

17

STAGE-I
Acute (primary) Infection
(Seroconversion)
Usually asymptomatic
30-50% may develop viral syndrome
- Fever
- Maculopapular rash
- Arthralgia, Myalgia
- Lymph node enlargement

HIV antibody tests are often

negative

18

MANIFESTATIONS OF
PRIMARY HIV INFECTION

19

STAGE-II
Early (asymptomatic)
disease
8-10 years asymptomatic period
In India, it is 5-7 years
Relatively symptom free/
minor symptoms

20

MINOR SYMPTOMS
Skin problems
Seborrhoeic dermatitis
Cellulitis
Pruritus
Herpes zoster reactivation

21

STAGE II
Investigation
CD4 count >500/mm3
Leucopenia &
Thrombocytopenia

22

STAGE III

(Intermediate HIV Infection)

Earlier known as Aids Related Complex
(ARC)
Recurrent HSV, HZV infection
Mild oropharyngeal or vaginal candidiasis
Oral hairy leucoplakia
Tuberculosis
Atypical
Extrapulmonary
Extensive
CD4 count 200-500/mm3
23

MINOR SYMPTOMS
Fever
Fatigue
Malaise

24

Stage IV : Late stage of HIV

disease
CD4 count 50-200/mm3
Stage V : Advanced HIV disease
CD4 count <50/mm3

25

INFECTIOUS CLINICAL CONDITIONS

IN HIV / AIDS
>500
ACUTE RETROVIRAL SYNDROME
CD4 CELLS CANDIDAL VAGINITIS

200 500
CD4 CELLS

PNEUMONIAS, PULMONARY TB,

HERPES ZOSTER, OROPHARYNGEAL CANDIDIASIS
ORAL HAIRY LEUKOPLAKIA, KAPOSIS SARCOMA &
CRYPTOSPORIDIOSIS (SELF LIMITED)

<200 CD4 CELLS

PCP, MILIARY/ EXTRA PULM. TB, DISSEMINATED

HISTOPLASMOSIS & COCCIDIODOMYCOSIS &
PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

<100 CD4 CELLS

<50 CD4 CELLS

DISSEMINATED HERPES SIMPLEX

TOXOPLASMOSIS,CRYPTOCOCCOSIS
CRYPTO / MICROSPORIDIOSIS
CANDIDAL OEGOPHAGITIS
DISSEMINATED CMV
DISSEMINATED MAC

26

NON INFECTIOUS CLINICAL CONDITIONS

IN HIV / AIDS
>500
CD4 CELLS

PERSISTENT GENERALISED LYMPHADENOPATHY (PGL)

GULLAIN BARRE SYNDROME
MYOPATHY & ASEPTIC MENINGITIS

200 500 CD4 CELLS

CERVICAL INTRAEPITHELIAL NEOPLASIA / CANCER

B-CELL & HODGKINS LYMPHOMA, ANAEMIA, PURPURA ,
MONONEURONAL MULTIPLEX
LYMPHOCYTIC INTERSTITIL PNEUMONIA (LIP)

<200 CD4 CELLS

WASTING, DEMENTIA, NON HODGKINS LYMPHOMA

PERIPHERAL NEUROPATHY, VACOLAR MYOPATHY,
PROGRESSIVE POLYRADICULOPATHY,
CARDIOMYOPATHY

<100 CD4 CELLS

<50 CD4 CELLS

CNS LYMPHOMA

27

CLINICAL FEATURES OF
AIDS
Opportunistic Infections
Disseminated CMV infection
C/c disseminated HSV infection
Progressive multifocal
leucoencephalopathy
Extensive/Extrapulmonary
tuberculosis
Atypical mycobacterial infection
PCP
28

CLINICAL FEATURES OF
AIDS(contd.)
Candidiasis of oesophagus,bronchi
C/c cryptosporidiosis
Toxoplasmosis of brain
Isosporiasis
Disseminated fungal infection
(histoplasmosis coccidiomycosis)
Cryptococcosis
Extraintestinal strongyloidiasis
29

SECONDARY NEOPLASMS
Kaposis sarcoma
Primary lymphoma of brain
Non Hodgkins lymphoma

30

OTHER SYMPTOMS
Prolonged fever
Significant weight loss
(10% or more in one month)
Cachexia
Chronic diarrhoea

31

SKIN MANIFESTATIONS
Infection
Neoplasm
Others

32

INFECTIONS
Herpes zoster /
simplex
Candidiasis
Molluscum
contagiosum
Folliculitis
Hairy leukoplakia
Percillium
marneffei
infection
33

INFECTIONS
Herpes zoster /
simplex
Candidiasis
Molluscum
contagiosum
Folliculitis
Hairy leukoplakia
Percillium
marneffei
infection
34

INFECTIONS
Herpes zoster /
simplex
Candidiasis
Molluscum
contagiosum
Folliculitis
Hairy leukoplakia
Percillium
marneffei
infection
35

INFECTIONS
Herpes zoster /
simplex
Candidiasis
Molluscum
contagiosum
Folliculitis
Hairy leukoplakia
Percillium
marneffei
infection
36

NEOPLASM
Kaposis sarcoma
Lymphoma
Basal cell
carcinoma

37

NEOPLASM
Kaposis sarcoma
Basal cell
carcinoma
Lymphoma

38

OTHERS
Pruritic papular
dermatitis
Seborrhoeic dermatitis
Drug rash
Vasculitis
Gingivitis

39

GASTROINTESTINAL
MANIFESTATIONS

Persistent diarrhoea
Cryptosporidiosis
Isospora
Shigella
Salmonella
E.histolytica
Giardia, MIcrospora
Colitis
Cytomegalovirus
Kaposis sarcoma

40

RESPIRATORY
MANIFESTATIONS
Symptoms
- Persistent cough
- Dyspnoea
- Cyanosis
- Hemoptysis
- Pleural effusion

41

Organisms causing
respiratory symptom
Mycobacterium tuberculosis
Bacterial pneumonia
Atypical mycobacteria
PCP, CMV
Fungi

42

Neurological Manifestations
Head ache lethargy

HIV encephalopathy

Dementia alaxia
Cryptococcal meningitis
Altered personality
CNS lymphoma
Convulsion
AIDS dementia complex
incontinence
Meningitis
Cryptococcal meningitis
Tubercular / Bacterial
43

HIV

NEPHROPATHY

Heavy proteinuria
Rapid deteriorations in renal function

44

CVS
Pericarditis ,Myocarditis , Endocarditis
Dil. Cardiomyopathy 25- 40%
Primary .Pulmonary Hypertension

Joint Manifestation
Polyarthritis
Reiters syndrome
Aggravation of psoriatic arthritis
45

PSYCHIATRIC
MANIFESTATIONS

ANXIETY DISORDERS
DEPRESSION
PANIC DISORDER
INSOMNIA
SUICIDAL TENDENCY

46

ENT

Otitis,externa/interna
Cellulitis of auricle
Sinusitis
Mastoiditis
Sensory neural deafness

EYE

Keratitis
Iridocyclitis
Retinitis-CMV,Toxoplasma
Orbital cellulitis

47

MAJOR SIGNS
1. Loss of body weight / failure to
thrive
2. Chronic diarrhoea
3. Prolonged fever

48

MINOR SIGNS
1. Repeated common infection
- Pneumonia
- Otitis
- Pharyngitis
2. Generalised lymphadenopathy
3. Oropharyngeal candidiasis
4. Persistent cough for >1 month
5. Disseminated maculopapular rash
49

Treating Opportunistic
Infection Among HIV-Infected

50

Cycle of Malnutrition and

Infection in HIV/AIDS

51

Rationale, Cont.
Opportunistic infections cause
symptoms such as anorexia and fever
that reduce food intake and nutrient
utilization and increase nutrient
requirements.
Reduced food intake and poor nutrient
absorption weaken the immune system
and hasten disease progression.
52

Rationale, Cont.

53

Importance of Managing
Symptoms at All Times
Rapid multiplication of the virus depletes
the host of nutrients and increases
vulnerability to infections.
Acting promptly and efficiently at the onset
of symptoms is critical to strengthen the
immune system and reduce the severity of
infections.
Nutritional repercussions and responses

54

Goals
Prevent malnutrition
Improve health and nutritional status
Slow the progression of the disease

55

Adequate Nutrition
Prevents malnutrition and wasting
Achieves and maintains optimal body weight
and strength
Enhances the bodys ability to fight
opportunistic infections
May help delay progression of the disease
Improves the effectiveness of drug treatments
Improves quality of life
56

Symptoms
and Nutritional Status
Symptoms such as loss of appetite, taste
changes,fever, diarrhea, nausea, vomiting,
oral
thrush, anemia, bloating, and heartburn may
negatively affect nutritional status because of
Reduced food intake
Poor nutrient absorption
Increased nutrient needs

57

Dietary Management
of Symptoms, Cont.

Anorexia: Eat small amounts of food frequently and

eat energy-dense foods
Thrush: Eat soft mashed foods cold or at room
temperature and avoid spices and sugar
Constipation: Eat more high-fiber foods and drink
plenty of fluids
Bloating and heartburn: Eat small and frequent
meals, avoid gas-forming foods, and eat long enough
before sleeping
58

Dietary Management
of Symptoms, Cont.

Diarrhea: Drink lots of fluids and eat energy-and

nutrient-dense foods
Nausea: Eat small frequent meals, avoid lying down
immediately after eating, rest between meals
Fever: Drink plenty of fluids and eat soups that are
rich in energy and nutrient foods
Anemia: Eat iron-rich foods, such as animal
products, green leafy vegetables. Take iron
supplement.
59

Conclusions
Dietary management of HIV/AIDS-related
symptoms helps maintain food intake and
compensate for nutrient losses
Dietary management complements medical
treatment and enhances the clients capacity to
fight opportunistic infections
Health workers and counselors should monitor
symptoms and food and drug regimen to ensure
nutritional status is maintained
60

61