HIV/AIDS

BY:
Mr. MUTEGEKI ADOLF
 Session Objectives
By the end of this session, leraners should be able to;
• Clearly understand the difference between HIV and AIDS.
• Understand the structure of HIV.
• Differentiate the characteristics of the different HIV
strains.
• Identify the modes of HIV transmission.
• Discuss risk factors for HIV acquisition.
• Identify the strategies of preventing against HIV
transmission
 HIV (Human Immunodeficiency Virus):
• HIV is a virus that attacks the immune system, specifically the CD4 cells (T cells), which
play a crucial role in the immune response.
• Over time, untreated HIV infection can lead to the severe depletion of CD4 cells,
weakening the immune system and making the individual susceptible to opportunistic
infections and certain cancers.
AIDS (Acquired Immunodeficiency Syndrome):
• AIDS is the advanced stage of HIV infection characterized by severe
immunosuppression.
• An individual is diagnosed with AIDS when their CD4 cell count falls below a certain
threshold, or they experience specific opportunistic infections or cancers associated
with advanced HIV disease.
• AIDS is a clinical diagnosis based on specific criteria established by health authorities
 HIV 1 and HIV 2
• Two HIV species are recognized:
• HIV-1, whose believed that the primate source was chimpanzees.
• HIV-2, originating from sooty mangabey monkeys. HIV-1 is found
worldwide and if untreated almost always progresses to AIDS.
• HIV-1 is divided genetically into groups M (‘main’), N, O and P.
• Group M is responsible for the global pandemic and is further
divided into nine subtypes or Clades e.g. A, B, C, D, E etc
• Each subtype is associated with a particular geographical area: for
example, subtype B dominates in the America and Australia
 HIV 1 and 2
Differences between HIV 1 and 2
HIV 1 HIV 2

Common in East and Common in West Africa

Southern Africa
Short incubation period Long incubation period

Very virulent Less virulent

Characteristics of HIV
• Exists in an unstable RNA status and can reverse transcribe to DNA
• Has receptor sites on the membrane
• Easily destroyed by heat (60c)
• Can only survive in humans
• Dies once out of human body
• Dies when body dies
• Attacks mainly WBC particularly CD4 cells
• High Multiplication ability

Note: HIV infection is a sexually transmitted infection (STI) except when

transmitted through infected blood and its products.
• Although HIV has no CURE yet, HIV and AIDS are both preventable
STRUCTURE OF HIV VIRUS
 MODES OF TRANSMISSION
• Unprotected Sexual Contact:
• Sharing of Contaminated Needles and Syringes (sharp objects):
• Mother-to-Child Transmission (Vertical Transmission):
• Blood Transfusions and Organ Transplants:.
• Occupational Exposure: Healthcare workers can be at risk of HIV
transmission if they are exposed to infected blood or body fluids through
needlestick injuries or mucous membrane contact.
• The use of universal precautions, proper handling of sharp objects, and
adherence to infection control measures help minimize the risk.
• Sexual Assault: In cases of sexual assault, if the perpetrator is HIV-
positive, there is a risk of transmission to the victim.
Factors influencing HIV transmission
A.Viral Factors
1.Type of virus: HIV 1 more likely to cause
infection than 2
2.Viral load: High viral load, ↑ risk of transmission.
B. Behavioral Factors
1. Number of Sexual partners
2. Abstinence reduces risk of HIV transmission
3. Unprotected sex
4. Alcohol and drug abuse
HIV Life Cycle
The HIV life cycle involves a series of steps that the virus must complete to replicate and
infect new host cells. Understanding the life cycle is crucial for developing antiretroviral
drugs and other interventions.
1. Attachment and Entry:
1.The HIV life cycle begins with the virus attaching to the surface of a
target cell. The viral envelope glycoprotein GP120 binds to the CD4
receptor on the host cell, usually a CD4-positive T lymphocyte or
macrophage.
2.The binding of GP120 to the CD4 receptor and co-receptor triggers
further conformational changes in the viral envelope glycoprotein GP41,
leading to the fusion of the viral and cellular membranes.
2. Reverse Transcription:
•Once the viral envelope fuses with the host cell membrane,
the viral RNA is released into the host cell cytoplasm.
•The enzyme reverse transcriptase converts the viral RNA
into DNA, a process known as reverse transcription.
•The newly formed viral DNA is then transported into the host
cell nucleus.
3. Integration:
•The viral DNA integrates into the host cell's DNA with the help of
the enzyme integrase.
•The integrated viral DNA, now called a provirus, becomes a
permanent part of the host cell's genetic material.
4. Transcription and Translation:
• The host cell's machinery transcribes the proviral DNA into messenger RNA
(mRNA).
• The mRNA is then translated into viral proteins by the host cell's ribosomes.
5. Assembly:
• Newly synthesized viral proteins, along with RNA and enzymes, move to the
cell membrane and assemble into new viral particles.
6. Budding:
• The assembled viral particles bud from the host cell, acquiring an envelope
derived from the host cell membrane.
• During the budding process, the viral protease enzyme cleaves the long viral
protein chains into individual functional proteins.
7. Maturation:
• The newly budded viral particles undergo maturation as
the protease continues to process and activate the viral
proteins.
• This final maturation step makes the virus infectious.
8. Release:
• The mature and infectious viral particles are released from
the host cell, ready to infect new target cells and initiate
the cycle anew
 END OF UNIT ASSESSMENT (Case Scenario)
• Teo is a 35 year old female, currently staying at Luzinga islands, with
her three children.
• Each of her three children has different fathers and is currently
cohabiting with 2 fishermen and occasionally meets with one of the
fathers for the last child for sexual favours.
• Teo‟s last born Maria has been unwell for the past one year with
frequent visits to the Health centre, the mother also reports delayed
milestones because Maria is only able to sit at one year.
• During one of the visits to the health centre the clinician talks to Teo.
1. What is the most likely diagnosis for Maria.
2. What health service package do you provide for Teo.
3. With relevant examples discuss the different risk factors for HIV
acquisition in Uganda.
Natural History of Disease
• The natural history of a disease refers to the course or
progression of a disease over time in the absence of medical
intervention.
• The natural history of HIV infection involves several stages,
from initial exposure to the development of AIDS (Acquired
Immunodeficiency Syndrome) if left untreated.
1. Exposure to HIV:
• The natural history begins with exposure to the human immunodeficiency virus (HIV),
typically through activities such as unprotected sexual intercourse, sharing of
contaminated needles, mother-to-child transmission during childbirth or breastfeeding,
or exposure to infected blood.
2. Acute HIV Infection:
• After exposure, individuals may experience an acute HIV infection phase, which occurs
within a few weeks of exposure.
• Symptoms during this phase can include
• fever,
• fatigue,
• sore throat,
• rash, muscle aches, and
• swollen lymph nodes.
Acute Phase ……
• This causes a rapid drop in CD4 T-Cell count as these cells are the
primary host for viral replication. Within several weeks patients mount
a strong immune response to the virus that causes a drop in the viral
titers.
• However, this response is not adequate to completely suppress viral
replication.
• Although viremia may become undetectable, replication persists in the
lymphoid organs.
• Although a significant number of patients do not have an acute HIV
syndrome, these processes do occur albeit without symptoms.
3. Asymptomatic or Chronic HIV Infection (Clinical Latency):
❖ Following the acute phase, the virus enters a clinically
asymptomatic or chronic stage.
❖ Although individuals may not experience significant symptoms
during this stage, the virus continues to replicate, and the
immune system is gradually compromised.
4. Clinical Latency (Chronic HIV Infection):
• The virus continues to replicate at lower levels, and individuals
may remain asymptomatic or experience mild symptoms during
this stage.
• The clinical latency stage can last for several years, but without
treatment, the immune system progressively weakens.
5. Progression to AIDS:
• If left untreated, HIV infection may progress to AIDS when the
CD4 cell count falls below a certain threshold, or specific AIDS-
defining illnesses (opportunistic infections or certain cancers)
occur. (200 cells/mm3)
• AIDS is the most advanced stage of HIV infection and indicates
severe immunosuppression.
6. Advanced HIV/AIDS:
• The eventual outcome of most HIV infections is gradual immune system
deterioration resulting in AIDS.
• Clinically apparent disease is classically diagnosed following an AIDS-defining
illness i.e. opportunistic infections (e.g., tuberculosis, pneumonia), certain cancers
(e.g., Kaposi's sarcoma), weight loss, chronic diarrhea, and neurological
symptoms
• That demonstrates a significant compromise of the immune system.
• Another diagnostic sign, although not strictly clinical, is the decline of CD4 T-cell
count below 200 cells/mm3.
• Without treatment, individuals diagnosed with AIDS may survive approximately
1-3 years.
• Individuals with advanced HIV/AIDS are susceptible to
 Distinct Patterns of Progression
• The natural course of untreated HIV infection varies widely. The past decade
has seen considerable interest in the identification of subgroups of HIV-
positive persons who exhibit distinct patterns of disease progression:
a). Long-term non progressors (LTNP) are individuals who remain
asymptomatic for a prolonged period of time off ART with a high CD4 cell
count.
• Although it is widely reported that 1–5% of the HIV-positive population are
LTNP, LTNP status can be lost, presence of ongoing (but low-grade) viral
replication.
• HIV RNA levels in plasma increased by 0.04 log10 copies/ml per year over the
first 8 years after diagnosis.
• As such, it is likely that virtually all HIV-positive persons will eventually
experience disease progression if left untreated.
b). Elite controllers or viral controllers are individuals who
are able to suppress HIV replication to such an extent that
viral load levels remain undetectable in the absence of ART.
As with LTNP, several studies have attempted to identify
factors associated with elite controller status.
• Loss of naive CD4 T cells seems to be a universal feature of
elite controllers, CD4 naive lymphocytes from elite
controllers tend to be less susceptible to HIV infection
Importance
• Natural history of HIV is widely studied and
understood today.
• It gives the basis of the WHO/CDC clinical staging of
HIV infection progression.
• It predictably covers what happens from time of
infection to death if no intervention is taken.
• It helps shows the risk of developing O.Is and AIDS
with CD4 decline.
• Basis of recommendations on treatment
interventions.
Clinical Presentation of HIV/AIDS
• The World Health Organization (WHO) clinical staging of HIV/AIDS is a
system used to classify the progression of HIV infection based on
clinical features and symptoms.
• It provides a framework for assessing the severity of the disease and
guiding treatment decisions.
• The WHO clinical staging is primarily used in resource-limited settings
where laboratory testing may be limited.
 Stage 1: Asymptomatic or Persistent Generalized
Lymphadenopathy (PGL):
• Individuals in this stage are asymptomatic or may
experience mild, nonspecific symptoms.
• PGL refers to persistent, unexplained enlarged lymph
nodes without other symptoms.
• CD4 cell count is generally above 500 cells/mm³
 Stage 2: Mild Symptoms:
➢Moderate weight loss (< 10% of presumed or measured body
weight)
➢Minor mucocutaneous manifestations (seborrheic dermatitis,
prurigo, fungal nail infections, recurrent oral ulcerations, angular
stomatitis/cheilitis)
➢Herpes zoster within the last 5 years
➢Recurrent upper respiratory tract infections (e.g. bacterial
sinusitis, tonsillitis, otitis media, and pharyngitis)
And/or performance scale 2: symptomatic but
normal activity
 Stage 3: Advanced Symptoms
(Advanced HIV Disease):
• Severe weight loss (more than 10% of presumed or
measured body weight)
• Unexplained chronic diarrhoea for longer than 1 month
• Unexplained persistent fever, intermittent or constant, for
longer than 1 month
• Persistent oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis
Stage 3……
• Severe bacterial infections (such as pneumonia,
pyomyositis, empyema, bacteraemia or meningitis)
• Acute necrotizing ulcerative stomatitis, gingivitis or
periodontitis
• Unexplained anaemia (< 8 g/dl),
• neutropenia (< 0.5×109 per litre), or
• chronic thrombocytopenia (< 50× 109 per litre)
And/or performance scale 3: Bed ridden
 Stage 4: AIDS (Severe AHD):
• HIV wasting syndrome: weight loss of more than 10% and
unexplained chronic diarrhoea for more than 1 month, chronic
weakness, or unexplained prolonged fever for more than 1
month
• Pneumocystis jirovecii pneumonia (PCP)
• Recurrent severe bacterial pneumonia
• Toxoplasmosis of the brain
• Cryptosporidiosis with diarrhoea for longer than 1 month
• Chronic isosporiasis (Isospora belli infection, is a GIT
infection caused by the protozoan parasite Isospora belli.)
 Stage 4 ………..
• Extrapulmonary cryptococcosis including meningitis
• Cytomegalovirus infection (retinitis or other organs)
• Herpes simplex virus (HSV) infection (orolabial, genital or anorectal
of >1 month’s duration or visceral at any site)
• Progressive multifocal leukoencephalopathy (PML)
• .Any disseminated endemic mycosis such as histoplasmosis,
coccidioidomycosis
• Candidiasis of the oesophagus, trachea, bronchi, or lungs
Stage 4 ………..
• Disseminated non-tuberculous mycobacterial infection
• Recurrent septicaemia (including non-typhoid
salmonella)
• Extrapulmonary tuberculosis
• Lymphoma (cerebral or B-cell non-Hodgkin)
 Stage 4 ………..
• Invasive cancer of the cervix
• Kaposi sarcoma
• HIV encephalopathy – disabling cognitive and/or motor dysfunction
interfering with activities of daily living, progressing slowly over weeks or
months, in the absence of concurrent illness or condition other than HIV
infection that could account for the findings
• Atypical disseminated leishmaniasis.
• Symptomatic HIV-associated nephropathy or symptomatic HIV associated
cardiomyopathy

And/or performance scale 4: Bed-ridden for more than

50% of the day during the last month
 Diagnosis and Investigations of HIV
• HIV testing is the point of entry into comprehensive care HIV services. Since an early
diagnosis is fundamental for early treatment, good prognosis and reduction in
transmission, HIV testing should be offered to all patients at any level of care and at any
occasion possible:
• provider- initiated HIV testing and counselling.
• Pre and post counselling and consent are needed except in the following situations:
• Diagnostic testing: test carried out on very sick, unconscious, symptomatic or mental
ill by attending health care team for the purpose of better patient management
• Routine testing: for individuals likely to pose a risk of HIV infection to others e.g.
pregnant and breastfeeding mothers, sexual offenders and survivors, blood or body tissue
or organ donors. Individuals tested using this approach must be given an opportunity to
know their status
• If a patient is positive, he/she must be IMMEDIATELY
connected to HIV care services.
• In adults and children >18 months, testing is based on
serological (antibody) testing.
• Serological testing is available from HC2 level.
• In children below 18 months, testing is virological, that is based
on direct detection of viral DNA (DNA-PCR).
• Due to the window period between infection and production of
detectable levels of antibodies, patients who are negative should
be re-tested after three months if they had a possible exposure
in the 3 months before the test.
HIV Testing Algorithm for testing persons above 18 months of age in Uganda
HIV Testing Algorithm using the HIV-Syphilis Duo Kit in MCH Settings
• For clients whose results are Inconclusive after the
recommended 14 days following a first inconclusive test result,
a sample should be collected, labelled “2nd INC” and sent to
the National Reference laboratory(CPHL) for testing.
• A result will be sent back as either POSITIVE or NEGATIVE.
• 1Within MCH settings, use HIV/Syphilis Duo test for women who
previously tested negative for HIV and Syphilis or those whose
status is unknown or those already known HIV positive (TRRK), test
for Syphilis using the single rapid Syphilis tests.
• For women with evidence of Syphilis treatment within a year, test
for HIV using the National Testing Algorithm Retesting for
verification in MCH setting: use the same algorithm as initial test
Other tests
•CD4 Count: Measures the number of CD4 cells to assess
the immune system's status.
•Viral Load: Quantifies the amount of HIV RNA in the
blood.
•Screening for Opportunistic Infections: Depending on
symptoms test may include:
•TB LAM
•Serum CAG (CrAg test)
Differential diagnoses
1.Infectious Mononucleosis (EBV):
2.Acute Viral Syndromes:
3.Bacterial Infections:
4.Autoimmune Disorders:
5.Lymphoma:
6.Streptococcal Pharyngitis (Strep Throat):
7.Primary HIV Infection (PHI):
 Management of HIV/AIDS
Minimum Service Package for PLHIV
• Clinical evaluation and monitoring of HIV disease: Clinical evaluation and
monitoring to ascertain the WHO clinical stage of disease and exclude
comorbidities.
• Antiretroviral therapy: ART initiation at the earliest opportunity in all people
with confirmed HIV infection, regardless of clinical stage or CD4 cell count
• Nutrition services: Nutrition assessment, counseling and support (NACS)
• Opportunistic infection screening, prevention, and management:
Cotrimoxazole prophylaxis, INH prophylaxis if eligible, Screen and manage OIs
like TB and cryptococcal infection
• Screening and treatment of comorbidities
• Screen and manage NCDs including:
✓Hypertension
✓Diabetes
✓ Dyslipidemias
✓Mental health (especially depression
• Sexual and reproductive health services:
✓Screening and management of sexually transmitted infections
✓Family planning and pre-conception services
✓Early identification of pregnant mothers and linkage to ANC
✓Facility delivery and postnatal care
✓Cervical and breast cancer screening
• Adherence counseling: Adherence preparation, monitoring and support
• Psychosocial support nd palliative care
✓Assessment for family and community support
✓Assessment for stigma and discrimination
✓Linkage to a psychosocial support groups
✓Assessment for social challenges
✓Referral for palliative care when required
• Orphans and vulnerable children (OVC)
✓ Assessment for vulnerability
✓HIV testing for family members
✓Referral and linkage to a CBO/CDO
✓Nutrition assessment, counseling and support
✓ART initiation for HIV-positive children and their caretakers
✓For details of OVC care, refer to the SPPI, Ministry of Labor, Gender, and Social
Development
• Positive health, dignity and prevention
✓Supported disclosure of HIV status to family and significant others
✓Active partner and family tracing for HIV testing
✓Education, distribution and promotion of condoms
✓Family planning/contraceptive counseling and services
✓STI screening, prevention and treatment services
✓Routine ART adherence counseling
✓Gender-based violence screening and support
Criteria for rapid ART initiation

ART Naïve/new • Do baseline CD4 and AHD symptom screen

• If CD4 less than 200 do TBLAM and CRAG
• Defer ART if symptom screen is Positive
People interrupting treatment (more than 90 days)
• Do a CD4 test and if more than 200 cells
• Restart old/previous ART regimen
• 3 IAC sessions for adherence support
• VL after 3 months
• Investigate for AHD, If CD4 test is less than 200 cells
 People interrupting treatment
(less than 90 days)
• No need for CD4 test
• Restart old/previous ART regimen if symptom
screen is negative
• Provide adherence support
• VL as per original schedule
The primary goal of Antiretroviral Therapy (ART)

• Suppression of Viral Replication:

• Preservation and Restoration of Immune Function:
• Reduction of HIV-Related Morbidity and Mortality
• Improvement in Quality of Life
• Prevention of HIV Transmission
• Prolonged Survival:
•Assessment of patient’s history
•Level of understanding of HIV/AIDS
•Length of time since the diagnosis of HIV infection
•Demographics and lifestyle: whether employed and
nature of work
•History of previous ART
•Pregnancy risks: contraception options and choices,
current or planned pregnancy, access to
contraceptive services
• Sexual risks and disclosure: willingness to practice
safer sex, disclosure of HIV serostatus, use of
condoms, HIV counselling, and testing of sex
partners and children
• Symptoms of chronic pain and depression
• History of opportunistic infections and other
significant illnesses e.g. TB and STIs,
hospitalizations, and surgeries
• Current medications (including anti-TB drugs,
traditional therapies, etc.)
Physical exam
• Weight
• Nutritional status
• Functional capacity and level of disability
• Vital signs, skin, eyes, oropharynx (presence of
thrush),
• lymph nodes, lungs, heart, abdomen, genital tract
(STIs), extremities, nervous system
•Baseline Labs to assess general health and
diagnose any pre-existing HIV complications
•Screen for TB and other AHD symptoms
•Staging of disease
•Develop an adherence plan
•Initiate the client on ART