Nadyn Permata A. L.

Agnes Maureen S
1906353353 1906296923

HIV/ AIDS
Diskusi Materi 1
Jumat, 5 Januari 2023

Supervisor: drg. Masita Mandasari, Ph.D, Sp.PM

 OUTLINE
1. Definition and classification
2. Epidemiology (prevalence, risk groups) in the world and Indonesia
3. Pathogenesis and risk factors
4. Progressions of HIV/AIDS
5. Examination and Diagnosis
6. Clinical signs and symptoms
7. Pharmacotherapy
8. Oral manifestations (EC Clearinghouse) of the disease and its management
9. Management in dentistry and infection control procedures
10. Dental emergencies, including prophylaxis for operators
11. Stigma among PLWHA
1.
Definitions & Classifications
 Definitions of HIV/AIDS
01. WHO 02. Scully
The human immunodeficiency virus (HIV)
targets the immune system and weakens HIV is a lethal retrovirus infection transmitted
people's defense against many infections and by blood and body fluids. HIV damages a subset
some types of cancer that people with healthy of cells (CD4+ cells) leading to severe T-helper
immune systems can more easily fight off. cell immune defects

AIDS

03. CDC laboratory-confirmed evidence of

HIV infection in a person who has
HIV is a virus that attacks the body’s stage 3 HIV infection (i.e. CD4+
immune system. If HIV is not treated, it lymphocyte count less than 200
can lead to AIDS (acquired cells/μL)x
immunodeficiency syndrome).

HIV. World Health Organization. World Health Organization. Available at: https://www.who.int/news-room/fact-sheets/detail/hiv-aids (Accessed: March 14, 2023).
About HIV/AIDS (2022) Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/hiv/basics/whatishiv.html (Accessed:March 14, 2023).
Scully C. Oral and maxillofacial medicine. 3rd ed. Edinburgh: Churchill Livingstone/Elsevier; 2013.
 Classification (CDC)

Clinical categories of HIV infection

The CD4 counts are defined as:
Category 1: ≥ 500 cells/mL
Category 2: 200–499 cells/mL
Category 3: < 200 cells/mL.
1. Scully C. Oral and maxillofacial medicine. 3rd
ed. Edinburgh: Churchill Livingstone/Elsevier;
2013.
- Category A (HIV infection): asymptomatic, persistent
generalized lymphadenopathy (PGL), acute (primary) HIV
infection with illness or history of acute HIV infection
- Category B (HIV disease): progressive HIV infection such as :
candidiasis, oropharyngeal (thrush) or vulvovaginal, oral hairy
leukoplakia, herpes zoster, etc.
- Category C : AIDS, ex: invasive cervical cancer, kaposi
sarcoma, toxoplasmosis of brain, etc.
 Classification

Glick, Michael (2015). Burket's Oral Medicine. (12th ed). People's Medical Publ. House USA
2.
Epidemiology
 Epidemiology In the World
Prevalence in 2022
39 Million people in the world were living
with HIV
1,5 million children (0-14 years old)
Incidence in 2022
1,3 million people, include 130.000
children (reduced 38% from 2010)
1. Scully C. Handbook of oral disease. Martin Dunitz; 1999.
2. HIV and AIDS. World Health Organization.
Dead from HIV in 2022
630.000 people ( reduced 51% than 2010) and
(reduced 69% than the peak in 2004 )
Receiving Treatment
people living with HIV in 2022, 86% knew
their status, 76% were receiving treatment
and 71% had suppressed viral loads
Age mainly affected : young adults
Sex mainly affected: M>F
 Epidemiology in Indonesia

4 key population in Indonesia:

- men having sex with men (MSM)
- Transgender
- female sex worker (FSW)
- injecting drug users (IDUs)

Based on 2022 data, 40% people with HIV died

1. http://p2p.kemkes.go.id/LayoutHIVAIDS-1
 Epidemiology in Indonesia

Prevalence of HIV in 2020 : 543.100,

which is the most key population is
in Papua Region (purple)

1. http://p2p.kemkes.go.id/LayoutHIVAIDS-1
3.
Pathogenesis and Risk Factors
 HIV transmision

1. Maartens, G., Celum, C. and Lewin, S.R. (2014) “HIV infection: Epidemiology, pathogenesis, treatment, and
prevention,” The Lancet, 384(9939), pp. 258–271. Available at: https://doi.org/10.1016/s0140-6736(14)60164-1.
 HIV Pathogenesis
HIV life cycle:
1.Binding and Fusion
2.Entry
3.Reverse transcription
4.Integration
5.Viral RNA and protein
expression
6.Assembly and budding
7.Maturation

Pathogenesis of HIV
- Acquisition of HIV
- Acute infection
- Chronic infection and
markers of progression
- AIDS

1. Pathogenesis of HIV Disease, uclahealth.org

 Risk factors
people with the conditions below get higher risk to HIV:

● having condomless anal or vaginal sex;

● having another sexually transmitted infection (STI) such as syphilis, herpes,
chlamydia, gonorrhoea and bacterial vaginosis;
● engaging in harmful use of alcohol and drugs in the context of sexual behaviour;
● sharing contaminated needles, syringes and other injecting equipment and drug
solutions when injecting drugs;
● receiving unsafe injections, blood transfusions and tissue transplantation, and
medical procedures that involve unsterile cutting or piercing; and
● experiencing accidental needle stick injuries, including among health workers.

HIV. World Health Organization. World Health Organization. Available at: https://www.who.int/news-room/fact-sheets/detail/hiv-aids
4.
Progressions of HIV/AIDS
 Stage 1 : Acute HIV Infection
● People have a large amount of HIV in their blood and are very contagious.
● Many people have flu-like symptoms.

Stage 2 : Chronic HIV Infection

● This stage is also called asymptomatic HIV infection or clinical latency.
● HIV is still active and continues to reproduce in the body.
● People may not have any symptoms or get sick during this phase but can transmit HIV.
● People who take HIV treatment as prescribed may never move into Stage 3 (AIDS).
● Without HIV treatment, this stage may last a decade or longer, or may progress faster. At
the end of this stage, the amount of HIV in the blood (viral load) goes up and the person
may move into Stage 3 (AIDS).

About HIV/AIDS (2022) Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/hiv/basics/whatishiv.html
 Stage 3 : Acquired Immunodeficiency Syndrome (AIDS)

● The most severe stage of HIV infection.

● People with AIDS can have a high viral load and may easily transmit HIV to others.
● People with AIDS have badly damaged immune systems. They can get an increasing number of
opportunistic infections or other serious illnesses.
● Without HIV treatment, people with AIDS typically survive about three years.

About HIV/AIDS (2022) Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/hiv/basics/whatishiv.html
5.
Examination and Diagnosis
 Examination & Diagnosis
EL󰈾󰈠󰉚 WE󰈠󰈙󰉋R󰈰 󰉔L󰈭󰈜 P󰉑󰈣
● ELISA method is the ● The Western blot test ● Used to detect HIV’s
screening test for separates the blood proteins genetic material RNA
identification of based on molecular weight ● Performed to
antibodies to HIV through gel electrophoresis determine the viral load
● It 90% sensitive but ● Then detects the specific in the blood & monitor
has a high rate of proteins (called HIV response to therapy
false negative antibodies) that indicate an ● Less used because
● If the results are HIV infection more expensive and
positive, a second ● The Western blot is used to also time and labor
ELISA is performed. confirm a positive ELISA intensive

Little J, Miller C, Rhodus N. Little and Falace's Dental Management of The Medically Compromised Patient. 9th ed. St. Louis: Elsevier; 2018.
6.
Clinical Signs and Symptoms
 Clinical Signs and Symptoms
● During the first 2 to 6 weeks after initial infection with HIV, more than 50% of patients develop an acute
flulike syndrome marked by viremia that may last 10 to 14 days. Others may not manifest this symptom
complex.
● Symptomatic persons often develop lymphadenopathy, fever, pharyngitis, and a skin rash but generally
do not display circulation antibodies until the sixth week to sixth month.
● The severity of the initial acute infection with HIV (i.e., level of viremia) is predictive of the course the
infection will follow.
● In one study, 78% of persons with a long-lasting acute illness developed AIDS within 3 years; by contrast,
only 10% of those patients with no acute illness at seroconversion developed AIDS within 3 years.

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 Clinical Signs and Symptoms
The CDC defines three stages of HIV infection

● Stage 1 generally begins immediately after HIV exposure and may last for years. Affected persons are HIV antibody
positive but are asymptomatic and show no other laboratory abnormalities.
● Stage 2 is characterized by progressive immunosuppression and symptomatic disease. Patients who demonstrate
various laboratory changes (i.e., lymphopenia: ratio of T helper to T suppressor usually <1) in addition to HIV
antibody positivity also may show clinical signs or symptoms, such as enlarged lymph nodes, night sweats, weight
loss, oral candidiasis, fever, malaise, and diarrhea.
● Persons in stage 3 have AIDS and can demonstrate a variety of immunosuppression-related diseases. Opportunistic
infections predominate as the CD4+ T count approximates 200 cells/μL; then malignancies, wasting syndrome, and
a progressive form of dementia can develop. Patients may become confused and disoriented or may experience
short-term memory deficits. Others develop severe depression or paranoia and show suicidal tendencies.
●

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
7.
Pharmacotherapy
 Medical Management
● Medical management of the HIV-infected patient has four main treatment goals:
○ to reduce HIV-associated morbidity and prolong the duration and quality of survival
○ to restore and preserve immunologic function
○ to maximally and durably suppress plasma HIV viral load, and
○ to prevent HIV transmission
● Long-term goals are to delay disease progression, prolong life, and improve quality of life.
● Treatment often is organized into three major areas:
○ ART
○ prophylaxis for opportunistic infections, and
○ treatment of HIV-related complications.

Monitoring response to therapy is a long-term requirement because more than 70% of HIV-infected persons
survive beyond 10 years from the time of diagnosis in the United States, especially if treatment is not delayed

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 ART and HAART
● The major goal of ART is to inhibit HIV replication completely such that the viral load is below the
detection limit of the assay at 4 to 6 months
● Both ART and HAART involve use of combinations of antiretroviral drugs; however, strictly speaking,
HAART is defined as the use of at least three active antiretroviral medications.
● ART increases survival, reduces systemic complications, and improves the quality of life in patients
infected with HIV.
● However, there are no conclusive studies that show when therapy should be initiated.
○ Experts recommend starting treatment in all patients with symptoms ascribed to HIV infection, all
pregnant mothers infected with HIV, and all HIV- infected infants.

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 ART and HAART
● More than 20 antiretroviral drugs are currently available for the management of HIV infection/AIDS
● The antiretroviral agents available are classified into five categories:
1. protease inhibitors (PIs)
2. nucleoside reverse transcriptase inhibitors (NRTIs)
3. non-nucleoside reverse transcriptase inhibitors (NNRTIs)
4. nucleotides, and
5. entry inhibitors.

These agents usually are used in combinations known as ART or HAART and should be given long term.

● A total of 29 antiretroviral drugs are approved by the Food and Drug Administration, and three-drug
combination regimens are the standard of care. The benefits of ART were extended to developing
countries, and an estimated more than 16 million people currently are taking ART worldwide.

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 ART and HAART
● Current guidelines from around the world now recommend starting ART in all
HIV-infected patients, regardless of CD4 cell count because of both clinical benefits
to the patient and reduction in HIV transmission to others
● Currently, preferred regimens for an ART-naive patient consist of
○ efavirenz + tenofovir + emtricitabine or
○ ritonavir-boosted atazanavir–darunavir plus tenofovir–emtricitabine, or
○ raltegravir + tenofovir + emtricitabine.
● Patients who respond to therapy generally show an increase in CD4+ count in the range
of 50 to 150 cells/μL per year and viral loads of less than 75 copies/mL.

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 Chemoprophylaxis
● Chemoprophylaxis regimens are recommended when CD4+ lymphocyte counts drop to
specific levels to prevent initial episode of a disease or to suppress a developing
opportunistic infection.
● These regimens exist for the prevention of
○ Pneumocystis pneumonia
○ tuberculosis
○ toxoplasmosis, and
○ other opportunistic diseases.

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
8.
Oral Manifestation & Management
 OROFACIAL CONDITIONS

HIV/AIDS ORAL MANIFESTATION

Oral lesions can be one of the early signs of

HIV infection and risk for progression to AIDS
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
EC-ClearingHouse
Classification
 GROUP 1
STRONGLY ASSOCIATED

Scully C. Oral and Maxillofacial Medicine the Basis of Diagnosis and Treatment. 3rded. Churchill Livingstone. 2013
Odell E, Cawson R. Cawson's essentials of oral pathology and oral medicine. 9th ed. Elsevier Ltd.; 2017
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 ORAL CANDIDIASIS

● Often the first oral sign

● Usually chronic or
erythematous in type

Treatment

● Single dose of 750 mg

fluconazole
 HAIRY LEUKOPLAKIA

● Epstein Barr Virus

● Asymptomatic, corrugated white lesion
of the lateral borders of the tongue
● Diagnosis: cell scrapings or a biopsy
● Histologic: koilocytosis and
hyperkeratotic, hairlike surface
projections from the lesion.
● Treatment: Antiviral agent
 KAPOSI SARCOMA

● HHV-8; Called ‘gay cancer’ by some since it is

transmitted sexually especially to MSM
● Presents initially as asymptomatic red, blue or
purple macules
● Progresses to papules, nodules or ulcers and may
become painful
● Diagnosis: a biopsy
 LYMPHOMA

● Seen in the maxillary gingival

● Soft painless swellings that ulcerate when traumatised.
● Most: non-Hodgkin B lymphomas (NHL) and Plasmablastic
lymphoma caused by HIV and EBV. Second commonest:
Burkitt's lymphoma
● Fairly resistant to therapy → poor prognosis
● Diagnosis: a biopsy
 GINGIVAL & PERIODONTAL DISEASES

● are painful
● are localized
● cause rapid alveolar bone loss
GINGIVAL & PERIODONTAL DISEASES
 GROUP 2
LESS COMMONLY ASSOCIATED

Scully C. Oral and Maxillofacial Medicine the Basis of Diagnosis and Treatment. 3rded. Churchill Livingstone. 2013
Odell E, Cawson R. Cawson's essentials of oral pathology and oral medicine. 9th ed. Elsevier Ltd.; 2017
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
VIRAL INFECTIONS
 VIRAL INFECTIONS

● Greater risk of intraoral secondary herpes infection. Severe orofacial zoster indicates disease

progression and a poor prognosis.

● Treatment with HAART causes a much higher risk of oral warts of all types, verruca vulgaris,

condyloma acuminatum and focal epithelial hyperplasia. → adverse effect of immune reconstitution.
 MOUTH ULCERS

Become more frequent and severe with

declining immune function
 SALIVARY CONDITIONS

● Chronic parotitis or hyposalivation in

children, possibly due to EBV or CMV →
almost pathognomonic of HIV infection
● A Sjögren’s-like syndrome with
xerostomia can affect adults.
 HYPERPIGMENTATION

Pigmentation in HIV infection is of unknown cause. It may

also be a complication of treatment with zidovudine
 THROMBOCYTOPENIC PURPURA

● The most common autoimmune

phenomenon in AIDS
● This can give rise to oral purple patches
that may be mistaken for Kaposi’s sarcoma,
petechiae or blood blisters.
 GROUP 3
SEEN IN

Scully C. Oral and Maxillofacial Medicine the Basis of Diagnosis and Treatment. 3rded. Churchill Livingstone. 2013
Odell E, Cawson R. Cawson's essentials of oral pathology and oral medicine. 9th ed. Elsevier Ltd.; 2017
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 BACTERIAL AND MYCOSES INFECTIONS

● Infections by bacteria that otherwise rarely involve the oral tissues, such as Klebsiella pneumoniae, Enterobacter
cloacae and Escherichia coli, can develop.
● Histoplasmosis or cryptococcosis can give rise to proliferative or ulcerative lesions. Histoplasmosis most
frequently affects the palate, gingivae and oropharynx.
OTHER VIRAL INFECTIONS
9.
Management in Dentistry & Infection Control
 Dental Treatment
● Standard Examination
○ Health history, EO and IO examination, complete periodontal and dental
examinations
● Patient at high risk for HIV infection
○ Patients may not answer questions honestly on account of the stigma or concern for
privacy
○ Verbal communication in a quiet and private location
○ Sharing of knowledge with atmosphere of honesty and openness
● Referred for HIV testing
○ Patients who are found to be at high risk for AIDS or related conditions → referred
for HIV testing and medical evaluation

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 Dental Treatment
The rights of dentists and patients with AIDS, including the following:

● Dental treatment may not be withheld if the patient refuses to undergo testing for HIV
exposure.
● A patient with AIDS who needs emergency dental treatment may not be refused
● If the dentist and the patient agree, the dentist may refer the patient to another provider
who is more willing or better suited
● The CDC and ADA recommend that infected dentists inform their patients of their HIV
serostatus and should receive consent

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 WHAT DENTIST SHOULD KNOW

Current CD4+ Lymphocyte

Presence, status of opportunistic infection, medications taken

For therapy or prophylaxis

Level of viral load

Susceptibility to opportunistic infection and rate of progression of AIDS

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
10.
Dental Emergencies & Prophylaxis for Operators
 Post Exposure Prophylaxis (PEP)
● The risk of HIV transmission from infected patients to health care workers is very low, reportedly
about 3 of every 1000 cases (0.3%) in which a needlestick or other sharp instrument transmitted blood
from a patient to a health care worker
● After a needlestick, the rate of transmission of HIV can be reduced by postexposure prophylaxis (PEP)
as soon as possible after exposure to HIV-infected blood.
● The number of PEP drugs recommended is based on the severity of the exposure as well as the HIV
status of the source patient.
○ A less severe exposure → two-drug PEP regimen
■ Solid needle or superficial injury from a source patient who is asymptomatic or has a low
viral load (<1500 viral copies/mL)
○ More severe exposure → Use of at least a three-drug PEP regimen
■ Large-bore hollow needle, deep puncture, visible blood on device or needle used in
patient’s artery or vein or when the patient is symptomatic, has AIDS, or a high viral load

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 Post Exposure Prophylaxis (PEP)
● The recommended basic regimen for HIV PEP is tenofovir + emtricitabine/ zidovudine + lamivudine.
● The expanded regimen includes a standard two-drug regimen plus a protease inhibitor such as
ritonavir-boosted (/r) lopinavir, darunavir/r, atazanavir/r, or raltegravir.
● PEP should be continued for 4 weeks, during which time the exposed clinician should be provided
expert consultation and follow-up monitoring for compliance, adverse events, and possible
seroconversion.
● Tests for seroconversion should be performed at 3, 6, and 12 months.
● Immediate action for any injury potentially contaminated with infectious body fluids
○ Wash with soap and water
○ Wounds should not be sucked or scrubbed
○ Splashes to the mucous membrane, including conjunctiva, should be irrigated copiously with
water (before and after removal of contact lens)

Odell E, Cawson R. Cawson's essentials of oral pathology and oral medicine. 9th ed. Elsevier Ltd.; 2017

Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the medically compromised patient. 9th ed
 11.
Stigma Among HIV/AIDS Patients

Facts about HIV stigma (2021) Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/hiv/basics/hiv-stigma/index.html
https://www.cdc.gov/stophivtogether/library/stop-hiv-stigma/fact-sheets/cdc-lsht-stigma-factsheet.pdf
 HIV Stigma
HIV stigma is negative attitudes and beliefs about people with HIV. It is the prejudice
that comes with labeling an individual as part of a group that is believed to be socially
unacceptable.

Example :

● Believing that only certain groups of people can get HIV

● Making moral judgments about people who take steps to prevent HIV transmission
● Feeling that people deserve to get HIV because of their choices
 HIV Discrimination
● Discrimination is the behaviors that result from those attitudes or beliefs
● HIV discrimination is the act of treating people living with HIV differently than
those without HIV

Example :

● A health care professional refusing to provide care or services to a person living

with HIV
● Refusing casual contact with someone living with HIV
● Socially isolating a member of a community because they are HIV positive
● Referring to people as HIVers or Positives
Effects of HIV Stigma and Discrimination
● Effect the emotional well-being and mental health of people living with HIV
● People living with HIV often internalize the stigma they experience and begin to
develop a negative self-image → judged negatively if their HIV status is revealed
● HIV internalized stigma can lead to feelings of shame, fear of disclosure, isolation,
and despair
○ These feelings can keep people from getting tested and treated for HIV
 Causes of HIV Stigma
HIV stigma is rooted in a fear of HIV

● Misconceptions about how HIV is transmitted

● The lack of information and awareness combined with outdated beliefs lead people
to fear getting HIV
● Many people think of HIV as a disease that only certain groups get
○ This leads to negative value judgements about people who are living with HIV
 What can be done about HIV stigma?
Learn how to talk Begin to take
Get the facts action
about HIV

Learn about HIV Normalize talk about Through our words and
facts HIV actions in our everyday
lives
Provides opportunities
to correct
misconceptions & help
others learn more
about HIV
THANK YOU