HIV and AIDS

ID specialist
Tamar Khuchua
 Defination
• Human Immunodeficiency virus infection (HIV-infection) is a slow progressive
chronic infectious disease which is caused by human immunodeficiency virus
(HIV).

• HIV affects and damages mainly human immune system.

• Immune system damage leads to acquired immunodeficiency syndrome (AIDS)

and uncontrolled carcinogenesis.

• AIDS is already the end-stage condition with severe damage of immune system
and appearance of single or multiple opportunistic infections.

• The consequences of these conditions are usually lethal.

• The lethal outcome is caused by opportunistic infections or various cancers.

Opportunistic Infections (OI) definition

• Infections caused by an organism capable of

causing disease only in a host whose
resistance is lowered (disease or drugs)
 Etiology
• Family – Retroviridae
subfamily – letiviruses
Human immunodeficiency virus – 1 (HIV-1)
Human immunodeficiency virus – 2 (HIV-2)
• RNA virus;
• 3 structural genes: gag (capside, matrix proteins),
env (envelope glicoproteins), pol (reverse
transcriptaze and other enzymes) and several other
regulator genes – regulating viral replication.
 Etiology
• HIV-1 and HIV-2
• HIV-1 and HIV-2 are two distinct viruses. Although tests which are sensitive to both types
of viruses are widely available, the significant genetic differences between the two types
mean that a test specifically designed to detect one type will not reliably identify the
other.

• Worldwide, the predominant, earliest and most commonly referred to virus is HIV-1. HIV-1
accounts for around 95% of all infections worldwide.

• The relatively uncommon HIV-2 virus is concentrated in West Africa, but has been seen in
other countries. It is less infectious and progresses more slowly than HIV-1, resulting in
fewer deaths. It is estimated to be more than 55% genetically distinct from HIV-1.

• While many commonly used antiretroviral drugs are active against HIV-2, non-nucleoside
reverse transcriptase inhibitors (NNRTIs) like nevirapine and efavirenz do not work against
it. The best strategy with which to treat HIV-2 has been less clearly defined than HIV-1.
 Virion structure
• Spherical virion;
• 100 nm in diameter;
• Consists of envelope and core.
• Envelope (encoded by gene env) consists of lipid
bilayer and structural glicoproteins (surface and
transmembrane - gp41/36, 120/105, 160/140);
• Core (encoded by gene gag) consists of matrix and
capsid (proteins - p17/18, 24/26, 55/56);
• Enzymes (encoded by gene pol) - p31, 51, 66/68.
 Stability in environment and sterilization

• HIV has no ability to survive in the environment;

• Inactivates on 56 0 C after 30 minutes and 1
minute after boiling; Standard disinfectants are
killing the virus;
• Relatively stabile against ionic radiation and
freezing at minus 70 0 C.
• May survive in the environment inside the drop
of blood and sperm.
 Pathogenesis - Target cells
• T lymphocytes expressing CD4 antigen
(helper inducer lymphocytes) – cell-mediated
immunity.
• Blood monocytes, tissue macrophages, B-
lymphocytes (humoral immunity).
• CNS macroglia, dendritic cells, vascular and
other endothelial cells.
 Pathogenesis
• Attachment to cell surface (CD4 receptor +
gp120);

• Fusion with cell membrane (gp 41);

• Endocytosis and entrance in the cell without

cell damage.
 Pathogenesis
• RNA - (reverse transcriptase) – single-strand
DNA - (reverse transcriptase) - double –
strand DNA - transporting to the cell nucleus
– (integrase) – itegration in the human
genome – new viral RNA – new viral proteins –
assembling new viral particle – shedding of
immature viruses from the cell – cell
destruction.
 Pathogenesis
• Viral cycle completes in 1-2 days;

• 10 billion new virions created and cleared

daily;

• 2 billion CD4 cells destroyed daily (twice the

rate of replacement by the hematopoietic
system)
 Pathogenesis
• Among new particles many are mutant strains
(occurring after dot-like mutations or after
recombination);
• New antigenic variants capable of escaping
the immune response;
• Some of them resistant to antiretroviral drugs.
 Pathogenesis
• HIV is directly cytopathic;
• HIV is damaging target cells indirectly:
 cyncitial cells are formed: between infected and non-
infected CD4 cells;
viral proteins have toxic effect on non-infected cells;
chronically infected cells have diminished function;
the ration of differect immune cells are changed. e.g.
decrease of CD4 and compensatory increase in CD8.
 Pathogenesis
• Immune response to HIV:
producing HIV antibody (occurs in serum after 1
month from infection – immunological window
period) is only partially effective, can not clear the
virus from the blood;
Excess activation of B-lymphocytes;
Bulk of immunocomplexes in blood circulation;
Disbalance in immunoglobulin production;
antigen-induced activation of proinflammatory
cytokines and triggering of autoimmune processes
 Pathogenesis
• Time passes and establishment of AIDS is
inevitable;
• Some adult patients are progressing slower,
some - quicker;
• In average - adult treatment-naive patients
progress to AIDS in ten years.
 History
• The beginning of the AIDS epidemic is often marked as 1981, when the
cases of five young homosexual men with puzzling manifestations of
immunodeficiency were reported from the city of Los Angeles. Because
the epidemic was first recognized among homosexual men, the acronym
GRID (“gay-related immune deficiency”) was initially proposed.

• However, when it became apparent that the disease was also affecting
intravenous (IV) drug users and blood transfusion recipients, the term
AIDS was adopted.

• It is remarkable that heterosexual intercourse, now by far the most

common mode of transmission worldwide, was not widely recognized as
a risk factor for AIDS until several years later.
 History
• After an intensive hunt for an etiologic microbe, the lentivirus
HIV-1 was shown to be the causative agent of AIDS in 1983–
1984. The virus was originally called LAV for lymphadenopathy
virus in France and HTLV-III for human T-cell lymphotropic virus
type 3 in the United States. Subsequently, the International
Committee for the Taxonomy of Viruses recommended the
current designation, HIV.
• Serologic tests for antibodies to HIV became widely available
in 1985. Only then, after serosurveys were conducted in at-risk
populations around the globe, was the staggering impact of
the pandemic in tropical regions appreciated.
 History
• Collectively these studies show that HIV
viruses—strains not dissimilar from
contemporary HIV strains—were present,
probably at low levels, in equatorial Africa in
the 1950s, 1960s, and early 1970s. However, it
was not until the late 1970s and early 1980s
that the AIDS epidemic became clinically
apparent in Africa.
 History
• By the end of 1984, a global pattern had emerged in
which most AIDS cases among Africans and Haitians,
whether they lived in their home countries or
abroad, were associated with heterosexual
intercourse, whereas most cases among North
Americans, Europeans, and South Americans (largely
Brazilians) were associated with homosexual sex or
IV drug use. Early reports of a relatively high AIDS
incidence regrettably led to irrational discrimination
against Haitians in the United States
 History
• 1987
• In February 1987, the WHO launched The Global Program on AIDS
to raise awareness; generate evidence-based policies; provide
technical and financial support to countries; conduct research;
promote participation by NGOs; and promote the rights of people
living with HIV.
• In March, the FDA approved the first antiretroviral drug,
zidovudine (AZT), as treatment for HIV.
• In April, the FDA approved the western blot blood test kit, a more
specific HIV antibody test.
• In July, the WHO confirmed that HIV could be passed from mother
to child during breastfeeding.
• In October, AIDS became the first illness debated in the United
Nations (UN) General Assembly.
 History
• 1988
• WHO declared 1st December as the first
World AIDS Day.

• The groundwork was laid for a nationwide HIV

and AIDS care system in the USA that was later
funded by the Ryan White CARE Act.
 History
• 1994
• AZT prophilaxi.s for perinatal transmission
 History
• At the end of 1995, the 15 countries of the
European Union account for an overwhelming
92.8% of all HIV infections reported across Eastern
and Western Europe. Two years later the situation
changes dramatically – the number of people living
with HIV in Eastern Europe increases more than
fivefold, with around 190,000 infections. Ukraine,
Russia and Belarus account for about 90% of all new
cases – the majority among people who inject
drugs.
 History
• 1996
• Following a number of breakthrough trials and new drugs, it
becomes clear during 1996 that combining a number of drug
types could have a dramatic effect on keeping HIV under control.

• Highly Active Antiretroviral Therapy ( HAART - combining at least

three drug types) is quickly incorporated into clinical practice in
rich nations, with an immediate decline of between 60% and
80% in rates of AIDS-related deaths and hospitalization.

• However, in low-income countries, even ten years later, less than

5% of those in need have access to this treatment
 History
• 2011
• The results of the groundbreaking HPTN 052 trial show that
people living with HIV and taking antiretroviral drugs were
96% less likely to transmit the virus to their partners. The
findings end a long-standing debate over whether
antiretrovirals could provide a double benefit by treating
the virus in individual patients while simultaneously cutting
transmission rates. The results prove that they could. This
was the first step in establishing treatment as prevention.
• The journal Science names the study the most important
scientific breakthrough of 2011.
 History
• 2015
• The World Health Organization publishes new
guidelines recommending that anyone
infected with HIV should begin antiretroviral
treatment as soon after diagnosis as possible.
This ‘treat-all’ recommendation responds to
findings from clinical trials confirming that
early use of antiretrovirals keeps people living
with HIV healthier and reduces the risk of
transmitting the virus to others
 History

• 30 June 2015 – Today, Cuba became the first country to

be validated by the World Health Organization (WHO)
to have eliminated mother-to-child transmission of HIV
and syphilis. The achievement marks a major progress
in global public health, Belarus, Armenia and Moldova
were next. 
 Global pandemics since 1982
• More than 70 million people have been infected
with the HIV virus worldwide
• 35 million people have died of HIV.
• Globally, 36.7 million [34.0–39.8 million] people
were living with HIV at the end of 2015.
• An estimated 0.8% [0.7-0.9%] of adults aged 15–
49 years worldwide are living with HIV.
• 70% of all people living with HIV worldwide live
in Sub-Saharan Africa .
 Epidemiology

• 36.7 million people lived with HIV/AIDS worldwide in 2016

• Of these, 1.8 million were children (<15 years old). Most of

these children live in sub-Saharan Africa and were infected
by their HIV-positive mothers during pregnancy, childbirth
or breastfeeding.

• 1.0 million people died of HIV-related illnesses worldwide

in 2016
 Terminology
• Prevalence in epidemiology is the proportion of disease
found to have been affecting a particular population
(typically a disease or a risk factor such as smoking or
seat-belt use) in a particular time period.

• Is usually expressed as a fraction, as a percentage or as

the number of cases per 10,000 or 100,000 people.

•  Incidence, which is a measure of new cases arising in a

population over a given period (month, year, etc.).
 Epidemiology

• Currently only 60% of people with HIV know

their status. The remaining 40% (over 14 million
people) still need to access HIV testing services. 

• As of June 2016, 18.2 million people living with

HIV were accessing antiretroviral therapy (ART)
globally, up from 15.8 million in June 2015, 7.5
million in 2010, and less than one million in
2000.
 Epidemiology- conclusions
• Although the incidence of HIV has apparently leveled off in much of the
developed world, it nevertheless continues to increase dramatically in
populations of the Caribbean, Latin America, sub-Saharan Africa, Asia,
and Eastern and Central Europe.
• Despite having only 10% of the world’s population, sub-Saharan Africa
contains almost two thirds of all people living with HIV.

• Because of the overwhelming immunosuppression associated with HIV

infections, it is also anticipated that many endemic bacterial and
parasitic diseases in these regions will increase dramatically. Diseases
such as tuberculosis, toxoplasmosis, cryptosporidiosis, isosporiasis, and
fungal infections, including cryptococcosis and Penicillium marneffei, will
become more prevalent and result in increasing morbidity and mortality
 Transmission

• HIV is detected in a variety of body fluids from infected

individuals: blood, breast milk, semen and vaginal secretions.

• HIV is transmited by: Sexual contact, blood transfusion,

unsterile syringes, mother-to-child (vertical, breast-feeding).

• Individuals cannot become infected through ordinary day-to-

day contact such as kissing, hugging, shaking hands, or sharing
personal objects, food or water.

• The virus is not transmitted with insect bites and human bites
(!).
 Transmission

• Sexual intercourse (most common source

worldwide);

• Exposure to contaminated blood;

• Maternal-fetus transmission (perinatal).

 Risk factors

• Having unprotected anal or vaginal sex;

• The risk of transmission after a single encounter with HIV
source is: 1 in 300-1000 with receptive anal intercourse,
1 in 500-1200 with receptive vaginal intercourse, 1 in
2000 with insertive vaginal intercourse.
• Risk is increased with having another sexually
transmitted infection such as syphilis, herpes, chlamydia,
gonorrhoea, and bacterial vaginosis;
• Risk is increased having an ulcer or tears on vaginal or
anal mucosa, also during menstruation.
• Risk is increased with the number of encounters and
higher HIV RNA in plasma.
 Risk factors

• Exposure to contaminated blood

• sharing contaminated needles, syringes and
other injecting equipment and drug solutions
when injecting drugs (e.g. ID users); risk is 1 in
150 with needle sharing.
• Receiving blood transfusions, tissue
transplantation (risk is 90%) ;
• Experiencing accidental needle stick injuries,
including among health workers (1/300).
 Risk factors
• Maternal-fetus transmission (perinatal) –risk is 15-45 %.
• All pregnant and breastfeeding women with HIV should
receive ARV.
• PreP with Truvada (tenofovir and emtricitabine) is
effective in 90%.
• 30 June 2015 – Today, Cuba became the first country to
be validated by the World Health Organization (WHO) to
have eliminated mother-to-child transmission of HIV and
syphilis. The achievement marks a major progress in
global public health, Belarus, Armenia and Moldova were
next. 
• PeP with ARV begins within 72 hours from the eccident
and is continues 28 days.
 Key populations

• Key populations are groups who are at increased risk of HIV

irrespective of epidemic type or local context. They include: men
who have sex with men (MSM), people who inject drugs (IDUs),
people in prisons and other closed settings, sex workers and their
clients, and transgender people.

• Key populations often have legal and social issues related to their
behaviors that increase vulnerability to HIV and reduce access to
testing and treatment programs.

• In 2015, an estimated 44% of new infections occurred among key

populations and their partners.
 Clinical course and natural history of
untreated HIV
• Depends on the amount of CD4 cell count;
• Viral load;
• Timing to progression to AIDS.
 CD4 cell count
• Normal value: 1000-1500 cells/mL
• Late presentation: Persons presenting for care
with a CD4 count below 350 cells/mL or
presenting with an AIDS-defining event,
regardless of the CD4 cell count.
• Presentation with advanced HIV disease:
Persons presenting for care with a CD4 count
below 200 cells/mL or presenting with an AIDS-
defining event, regardless of the CD4 cell count.
Classification of HIV infection and AIDS
 Clinical category A
• Asymptomatic HIV infection
• Persistant generalized lymphadenopathy (PGL)
• Acute HIV infection, or history of acute HIV
infection
 Clinical category B
Explanation: Attributed to HIV infection or indicate a defect in cell-mediated
immunity. Are considered to have a clinical course or management that is
complicated by HIV infection

Condition list:
•Bacillary angiomatosis
•Oropharyngeal candidiasis (thrush)
•Vulvovaginal candidiasis, persistent or resistant
•Pelvic inflammatory disease (PID)
•Cervical dysplasia (moderate or severe)/cervical carcinoma in situ
•Hairy leukoplakia, oral
•Herpes zoster (shingles), involving two or more episodes or at least one dermatome
•Idiopathic thrombocytopenic purpura
•Constitutional symptoms, such as fever (>38.5°C) or diarrhea lasting >1 month
•Peripheral neuropathy
 Clinical category C
• Bacterial pneumonia, recurrent (two or more episodes in 12 months)
• Candidiasis of the bronchi, trachea, or lungs
• Candidiasis, esophageal
• Cervical carcinoma, invasive, confirmed by biopsy
• Coccidioidomycosis, disseminated or extrapulmonary
• Cryptococcosis, extrapulmonary
• Cryptosporidiosis, chronic intestinal (>1 month in duration)
• Cytomegalovirus disease (other than liver, spleen, or nodes)
• Encephalopathy, HIV-related
• Herpes simplex: chronic ulcers (>1 month in duration), or bronchitis, pneumonitis, or esophagitis
• Histoplasmosis, disseminated or extrapulmonary
• Isosporiasis, chronic intestinal (>1-month in duration)
• Kaposi sarcoma
• Lymphoma, Burkitt, immunoblastic, or primary central nervous system
• Mycobacterium avium complex (MAC) or Mycobacterium kansasii, disseminated or extrapulmonary
• Mycobacterium tuberculosis, pulmonary or extrapulmonary
• Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
• Pneumocystis jiroveci (formerly carinii) pneumonia (PCP)
• Progressive multifocal leukoencephalopathy (PML)
• Salmonella septicemia, recurrent (nontyphoid)
• Toxoplasmosis of brain
• Wasting syndrome caused by HIV (involuntary weight loss >10% of baseline body weight) associated with either
chronic diarrhea (two or more loose stools per day for ≥1 month) or chronic weakness and documented fever for ≥1
month
 Acute HIV symptoms

General:
• Fever, pharyngitis, lymphadenopathy, headache,
arthralgia, myalgias, anorexia, nausea, vomiting,
diarrhea
Neurologic:
• meningitis, encephalitis, myelopathy, neurophathy
Skin:
• Maculopapular rash,
• ulcers
 Basic opportunistic infections in category C
• 500 cells/mm3 to 200 cells/mm3

Kaposi’s Sarcoma (KS)

(Human Herpes Virus-8)

Signs and Symptoms of KS can include:

• Appearance of a purplish lesion on skin
• Appearance of a purplish lesion in the mouth
• Occasionally gastrointestinal complaints with disseminated KS

Candidiasis (esophageal or bronchial)

 Basic opportunistic infections
• 200 cells/mm3 to 100 cells/mm3
Pnuemocystis Jirovecii (Carinii) Pneumonia (PCP)
• - Signs and Symptoms of PCP can include:Shortness of Breath
• Fever
• Dry Cough
• Chest Pain
Histoplasmosis and Coccidioidomycosis
• Signs and Symptoms of Histoplasmosis and Coccidioidomycosis can include: Fever
• Fatigue
• Weight Loss
• Cough
• Chest pain
• Shortness of Breath
• Headache
Progressive Multifocal Leukoencephalopathy (PML)
• Signs and Symptoms of PML can include :Dementia
• Seizures
• Difficulty Speaking
• Confusion
• Difficulty walking
 Basic opportunistic infections
• 100 cells/mm3 to 50 cells/mm3 • Cryptococcal Meningitis include:
• Signs and Symptoms of Toxoplasmosis – Fever
– Fatigue
can include:
– Headache
– Headache – Neck Stiffness
– Confusion – Some patients can have memory loss or mood
– Motor Weakness changes
– Fever
– Seizures CMV.
• – Signs and Symptoms of CMV:
• Sore Throat
Signs and Symptoms of • Swollen Glands
Cryptosporidiosis can include: • Fatigue
– Chronic Watery Diarrhea • Fevers
– Stomach cramps
In people with low CD4 counts it can cause:
– Weight loss • Blurred vision ( if there is CMV infection is in the eye)
– Nausea • Painful Swallowing
– Vomiting • Diarrhea
• Abdominal Pain
 Basic opportunistic infections
• Less than 50 Cells/mm3

• Mycobaterium Aviam Complex (MAC)

MAC is a type of bacteria that can be found in soil, water, and many places in the environment. These
bacteria can cause disease in people with HIV and CD4 Counts less that 50. The bacteria can infect the
lungs or the intestines, or in some cases, can become “disseminated”. This means that it can spread to
the blood stream and other parts of the body. If this occurs, it can be a life threatening infection. If a
persons CD4 count is below 50, then medications are available to prevent this infection from occurring.

– SYMPTOMS
• Signs and Symptoms of MAC:
– Fevers
– Night sweats
– Abdominal Pain
– Fatigue
– Diarrhea
 HIV and TB
• Undetected or untreated TB is the leading
cause of death among people with HIV,
responsible for 1 of 3 HIV-associated deaths.
• Despite the CD 4 cell count;
 Clinical categories
• What does it mean for general practitioner?
• Patients presenting with certain medical
conditions have a higher prevalence of
undiagnosed HIV compared to others.
• General practitioners should screen patients
for undiagnosed HIV if they present with the
conditions listed below:
 Clinical categories
• What does in mean for different speciality
doctors?

• Screening recommendations according the

medical specialty specialty are listed below:
 Diagnosis
• Across Europe, almost one-third of individuals infected
with HIV do not enter health care until late in the course of
their infection.
• Despite attempts to encourage earlier testing for HIV, this
situation has remained stationary for several years without
evidence of improvement. Late presentation for care is
harmful to the infected person , is more costly and is
harmful to society.
• Surveillance to identify the extent to which late
presentation occurs is therefore crucial and remains
inadequate across Europe, and is further complicated by
the lack of a common clinical definition of late presentation
 Diagnosis
• HIV infection is often diagnosed through rapid
diagnostic tests (RDTs), which detect the
presence or absence of HIV antibodies. Most
often these tests provide same-day test results,
which are essential for same day diagnosis and
early treatment and care.
• Used for screening
• Detects antibodies against HIV mainly with
ELISA (enzyme linked immunosorbent assey)
Diagnosis
 Diagnosis
• Confirmative tests are immunobloting assey
(Western Blot) and polymerase chain
reaction (PCR);

• More expansive;

• More time-consuming.
 Diagnostics
• Western blot:
1) Positive: at least two of the following bands
positive: gp24, gp41, gp 160/120.
2) Negative: no bands;
3) Indetermined: only single band is positive
(seroconversion in progress, advance HIV with
loss of antibody response, cross-reacting
antibodies or autoimmune antibodies) –
requires checking HIV RNA
 Testing
• All HIV testing services must follow the 5 Cs
principles recommended by WHO:
• Informed Consent
• Confidentiality
• Counselling
• Correct test results
• Connection (linkage to care, treatment and
other services, e.g. Tuberculosis care center).
 Treatment

• There is no cure for HIV infection. However, effective antiretroviral

(ARV) drugs can control the virus and help prevent transmission so
that people with HIV, and those at substantial risk, can enjoy
healthy, long and productive lives.

• Between 2000 and 2016, new HIV infections fell by 39%, and HIV-
related deaths fell by one third with 13.1 million lives saved due to
ART in the same period. This achievement was the result of great
efforts by national HIV programmes supported by civil society and
a range of development partners.
 Goal Of Antiretroviral Therapy (ARV)

• To suppress HIV RNA (viral load) as low as

possible as long as possible;
• To preserve or enhance the immune system;
• To delay the progression of HIV;
 ARV pro and con
• To delay the progression • Drug toxisity
of HIV • Occuring resistant virus
• HIV RNA decrease, • Regimen adherence
• Immunological • In early disease the
impairment progression is low
• Reduction of • Long term effects are
transmission unknown.
 ARV Drugs
• Main categories:
1. Entry inhibitors (e.g. fusion and co-receptor)
2. Reverse transcriptase inhibitors:
2.1 Nucleoside/ nucleotide analoges (NRTI)
e.g. Lamivudin
2.2Non-nucleoide inhibitor (NNRTI)
3. Protease inhibitors
4. Integrase inhibitors
Initial ART treatment in previously
untreated patients

2 NRTIs
+
1 NNRTI, or 1 Protease inhibitor, or 1 Integrase
inhibitor
 Complications of treatment
• Drug toxicity;
• Occurrence of the resistant virus;
• Immune reconstitution syndrome.
Treatment of main opportunistic infections
 Prophylaxis and prevention
• Testing and counseling for HIV and STIs.
• Testing and counseling, linkages to tuberculosis care
• Voluntary medical male circumcision (VMMC).

• Pre-exposure prophylaxis (PrEP) for HIV-negative partner with Truvada (tenofovir +

emtricitabine);

• Post-exposure prophylaxis for HIV (PEP) with ARV (two drugs combination or three
drugs combination) begins within 72 hours from the accident and is continues 28 days.
• Basic two drugs combination: two nucleoside analogues (e.g., ZDV and 3TC; or 3TC
and d4T; or d4T and ddI).
• Expanded three drugs regimen: basic regimen + one more drug.
• Harm reduction for people who inject and use drugs;
• Condom, barrier contraceptives;

• Elimination of mother-to-child transmission of HIV (EMTCT) - All pregnant and

breastfeeding women with HIV should receive ARV.
 Clinical course
• HIV infected people are not only suffering from
opportunistic infections;
• They also are more prone to non-infectious
disease and frailty compared to general
population.
• Also they may experience drug-toxicity.
• Below the conditions are listed which can be
diagnosed in HIV-positive patients according
medical specialty:
 Cardiovascular findings
Causes: Infection
• Mycobacterium
• Nocardia
• Cryptococcus neoformans
• Histoplasma capsulatum
• Aspergillus
• Cytomegalovirus (CMV)
• Epstein-Barr Virus (EBV)
• Toxoplasmosis
 Cardiovascular findings: non-infectious
Common
– Coronary Artery Disease
• Longstanding HIV carries a coronary disease equivalent risk similar to Diabetes Mellitus
• CD4 Count <500 is associated with an increased risk of coronary events (even if it rebounds)
• Patients with HIV also have higher rates of Tobacco abuse and Hypertension
– Cerebrovascular Disease
• Secondary to direct HIV neurotoxicity, opportunistic infections, coagulopathy, chronic inflammation
• Patients with HIV also have higher rates of Tobacco abuse, IVDA, CAD, Hypertension, CKD
• Strokes occur at younger ages in HIV patients (esp. with lower CD4 Counts, higher viral loads)
– Dyslipidemia
• Obtain lipid panel and Serum Glucose at time of HIV diagnosis
• Repeat lipid panel and Glucose screening at perioidic intervals
• Consider Statins if indicated (based on non-HIV Infection guidelines)
– Risk of Statin-related Drug Interactions with Protease Inhibitors, NNRTI agents
– Dilated Cardiomyopathy (25% advanced HIV)
– Left Ventricular Dysfunction (21% advanced HIV)
– Myocardial fibrosis
• Present in up to 82% of HIV patients and often asymptomatic

Less common
– Myocarditis
– Pericardial Effusion
– Pericarditis
– Arrhythmias

Rare Conditions
– Endocarditis
 GI findings
• Infectious esophagitis, Gastroenteritis and
colitis
– Dysphagia in HIV (or Odynophagia in HIV)
– Nausea in HIV (or Vomiting in HIV)
– Gastritis in HIV
– Gastric Outlet Obstruction in HIV
– Diarrhea in HIV
 GI findings
• Infiltrative hepatobiliary infections
– AIDS Cholangiopathy
– Hepatitis in HIV
– Peliosis Hepatitis
• Infiltrative pancreatic infections
– Pancreatitis in HIV
• Rectal lesions
– Genital Warts (especially anorectal warts)
– Anorectal lesions (consider Colorectal Cancer)
• Medication adverse effects: Antiretroviral therapy
– Nausea, Dyspepsia and Diarrhea
• Common adverse effects (esp. Protease Inhibitors)
• Inquire about side effects at each visit to prevent non-compliance
– Hepatotoxicity
• Protease Inhibitors (esp. older agents)
• Nevirapine (NNRTI)
– Withdrawal of NRTI (Emtricitabine, Lamivudine, Tenofovir)
• Agents have activity against Hepatitis B Infection (in addition to HIV Infection)
• Hepatitis BVirus Infection may flare when these medications are stopped
 Pulmonary findings
Epidemiology: HIV and Tobacco abuse both play major roles in the increased risk of COPD and Lung Cancer in HIV patients

General causes of lung infection in HIV:

• Typical Bacterial Pneumonia occurs in HIV patients
– Pneumococcal Pneumonia
– Haemophilus Influenzae
• Tuberculosis occurs in advanced HIV with CD4 < 500
• Pneumocystis occurs in advanced HIV with CD4 < 200
Causes: Cavitary Lesions
• Tuberculosis
• Aspergillus
• Pneumocystis carinii
• Pneumococcus
• Cryptococcus neoformans
• Rhodococcus equi
• Gram Negative Bacilli (especially Pseudomonas)
Causes: Nodular lesions
• Cryptococcus
• Histoplasmosis
• Tuberculosis
• Pneumocystis carinii
• Bacterial Pneumonia
 Pulmonary findings
Malignancies
– Kaposi's Sarcoma
– Non-Hodgkin's Lymphoma
Causes: Hilar Adenopathy
• Tuberculosis
• Kaposi's Sarcoma
• Non-Hodgkin's Lymphoma
• Pneumocystis carinii (Uncommon)
Causes: Pleural Effusion
• Tuberculosis
• Fungal Pneumonia
• Kaposi's Sarcoma
• Non-Hodgkin's Lymphoma
Prevention
• Tobacco Cessation
• Pneumococcal Vaccine
• Influenza Vaccine
 Neurological findings
Epidemiology
• HIV patients with neurologic complications: 39-70%
Symptoms: Common presentations
• Seizures
• Headache
• Fever
• Focal neurological deficits
– See Focal Brain Lesion in HIV
• Aseptic Meningitis at time of seroconversion
– See Acute Retroviral Syndrome
– CSF shows lymphocytic Pleocytosis and high protein
 Neurological findings
Associated Conditions: Neurologic
• AIDS Dementia Complex
• HIV related Myelopathy
• HIV Related Neuropathy
• Headache in HIV
• Primary Central Nervous System Lymphoma
– Presents with Headache, blurred vision, Seizures, personality or cognitive changes
– MRI demonstrates solitary white matter lesions with mild edema
– Diagnosed with CSF Examination, brain biopsy
• CNS Infections
– See Focal Brain Lesion in HIV
– HIV-Related Encephalopathy
– Cryptococcal Meningitis
– Toxoplasmosis (CNS Infection)
– Neurosyphilis
– Progressive Multifocal Leukoencephalopathy
– Viral meningoencephalitis
• Cytomegalovirus (CMV)
• Herpes Simplex Virus Encephalitis (HSV Encephalitis)
• Varicella Zoster Virus (VZV)
 Renal findings
Associated Conditions: Renal dysfunction
• HIV Nephropathy (AIDS associated Nephropathy)
• Fluid and electrolyte abnormalities
– SIADH and Hyponatremia common due to occult infection
• Drug induced Renal toxicity
– See Nephrotoxic Drug
– Amphotericin B
– Foscarnet
– Pentamidine
– Bactrim
– NSAIDs
– Tenofovir Disoproxil fumarate (TDF)
• Causes proximal tubule dysfunction (e.g. Hypophosphatemia) and decreased Renal Function
• Avoid if GFR <60 ml/min and discontinue if GFR falls more than 25% or <60 ml/min
• May safely use Tenofovir Alafenamide as alternative (less nephrotoxic)