THE TIME TO ACT IS NOW……..

Prevention, Diagnosis and Management of

HIV AIDS

Dr. Mohin M SakrePost graduate Student

Dept of Community MedicineKBNIMS

Clinical Presentations of HIV AIDS

The clinical features of HIV infection have been classified in four broad categories:

• Initial infection with the virus and development of Antibodies.

• Asymptomatic carrier state.• AIDS related complex.• FULL BLOWN AIDS

The UN defines adolescents as persons aged 10−19 years but, in the present document, the category of adults and adolescents comprises people aged 15 years and over for surveillance purposes.

REVISED WHO CLINICAL STAGING OF HIV/AIDS

Primary HIV

Infection

Clinical stage 1

Clinical stage 2

Stages where a presumptive diagnosis can’t be made only on the basis of clinical signs or simple investigations. Confirmatory diagnosis can be achieved by CD4 count or percentage

REVISED WHO CLINICAL STAGING OF HIV/AIDS

Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations.

Clinical stage 3

Clinical stage 4

In clinical stage 4, there are a few conditions that have to be tested via prescribed tests to be classified as AIDS(According to WHO)

SIGNIFICANCE OF CD4 CELLS IN IMMUNOLOGICAL STAGING

• CD4 cells are a kind of lymphocytes that activate your body's immune system in case of an invasion. They are also called T cells or helper T cells. Normal: 500-1600.

• CD8 cells are suppressor T or killer T cells.

SIGNIFICANCE OF CD4 CELLS IN IMMUNOLOGICAL STAGING

• CD4 percentage is said to be of more use since CD4 counts can widely fluctuate. The normal range of % is 40-45%. A CD count of less than 200 corresponds to a % of less than 17%.

• Clinical staging can be used effectively without access to CD4 or other laboratory testing. However, CD4 testing is useful for determining the degree of immunocompromise

CD4 LEVELS IN RELATION TO THE SEVERITY OF IMMUNOSUPPRESSION IN ADULTS AND

ADOLESCENTS.

•>500/mm3Not significant immunosuppression

•350 − 499/mm3Mild immunosuppression

•200 −349/mm3Advanced immunosuppression

•<200/mm3Severe immunosuppression

CD4 LEVELS IN RELATION TO THE SEVERITY OF IMMUNOSUPPRESSION IN INFANTS AND

CHILDRENIMMUNE STATUS AGE UPTO 12

MONTHSAGE FROM 13-59 MONTHS

AGE FROM 5 YEARS AND OVER

NOT SIGNIFICANT

MORE THAN 35% MORE THAN 25% GREATER THAN 500/MM3

MILD 25-34% 20-24% 350-499/MM3

ADVANCED 20-24% 15-19% 200-349/MM3

SEVERE LESS THAN 20% LESS THAN 15% LESS THAN 200/MM3

CLINICAL AND IMMUNOLOGICAL CRITERIA FOR INITIATING ART IN ADULTS

AND ADOLESCENTS

Clinical stage 4: ART Treat.

Clinical stage 3: Consider treatment:

CD4, if available, can guide the urgency with which ART should be

started.

Clinical stage 1 or 2: Only if

CD4 <200/mm3.

CLINICAL AND IMMUNOLOGICAL CRITERIA FOR INITIATING ART IN

INFANTS AND CHILDREN

Clinical stages ART4: Treat.

Presumptive stage 4: Treat.

Stage 3:Consider

treatment for all ages. Children aged under 2 years usually require

ART. CD4 %, if available should be used to guide decisions on

ART.

1 and 2:Usually only where

CD4 available.• Under 12 months: CD4 % < 20• 13-59 months : CD4 % < 15• 5 years or over CD4

<200/mm3

ADVANCED HIV/AIDS DISEASE DEFINITIONS FOR SURVEILLANCE FOR

ADULTS AND ADOLESCENTS

Any clinical stage 3 or stage 4 diseaseor,

where CD4 is available, any clinical stage and CD4 <350/mm3

ADVANCED HIV/AIDS DISEASE DEFINITIONS FOR SURVEILLANCE FOR

INFANTS AND CHILDREN

Clinical stage 3 or stage 4 disease at any ageor

where CD4 is available, any clinical stage with CD4 % <25% in children aged under 12 months

CD4 % <20% in children aged 12 -59 months CD4 <350/mm3 in children aged 5 years and above

Relation between CD4 levels and development of Opportunistic infections.

500/MM3: BACTERIAL INFECTIONS, TB, HERPES

SIMPLES AND ZOSTER, VAGINAL CANDIDIASIS, HIARY

LEUKOPLAKIA, KAPOSIS SARCOMA

200/MM3: PNEUMOCYSTOSIS, TOXOPLASMOSIS,

CRYPTOCOCCOSIS, COCCIDIODOMYCOSIS, CRYPTOSPORIODOSIS.

50/MM3: DISSEMINATED MAC INFECTION,

HISTOPLASMOSIS, CMV RETINITIS, CNS LYMPHOMA.

LABORATORY TESTS

ELISA

HIV Viral load tests

Detection of Viral nucleic

acid

p24 antigen:

Western Blot.

CBC.

CD4 count.

CD4 percentage

B2 Micro globulin.

Antibody detection, though specific is hardly preferred because of the significantly long window period.

CLINICAL DIAGNOSIS OF AIDS. WHO case definition for AIDS surveillance

In adults and adolescents

• Major signs(2 or more):Weight loss, Persistent fever, chronic diarrhea.• Minor signs(1 or more):Persistent cough, Generalised pruritic dermatitis, H/O

Herpes zoster, Orpoharyngeal Candidiasis, Herpes simplex.

Children

• Major signs(2 or more):Weight loss, slow growth, chronic diarrhea and fever for more than a month.

• Minor signs(2 or more):Generalized Lymphadenopathy, Recurrent common infections, Persistent cough and generalised rash.

Infant

• HIV antibody positive ( ELISA or RAPID ) aged under 18 months and symptomatic with 2 or more of the following: Oral thrush, severe pneumonia, severe wasting and malnutrition, severe sepsis, recent HIV related maternal death, advanced AIDS in mother, confirmed AIDS in mother.

Expanded WHO case definition for AIDS surveillance.

More than 10% of the body weight

lost with fever or cachexia or

both for a month.

Cryptococcus meningitis

Pulmonary or extra

pulmonary TB

Kaposi's sarcoma

Neurological impairment

Candidiasis of the Esophagus

Clinically diagnosed life threatening or

recurrent episodes of

clinical Pneumonia

An adult or an adolescent is said to have AIDS if one of the tests for HIV antibody gives a positive result and one or more of the following are present:

Curative ManagementOf

AIDS

Classification of drugs used for ART (Anti retroviral therapy)

• Abacavir(ABC), Didanosine(DDL), Lamivudine(3TC), Stavudine(D4T), Zidovudine(AZT), Emtricitabine(FTC)

NUCLEOSIDE REVERSE TRANSCRIPTASE

INHIBITORS(NRTIs)

• Raltegavir(RAL)

INTEGRASE STRAND TRANSFER

INHIBITORS(INSTIs)

• Atazanavir+ritonavir(ATV/r), Darunavir+ritonavir(DRV/r), Fos-amprenavir+rotinavir(FPV/r), Indinavir+ritonavir(IDV/r), ritonavir/lopinavir(LPV/r), saquinavir, indinavir(SQV/r).

PROTEASE INHIBITORS(PIs)

• Tenofovir(TDF)NUCLEOTIDE REVERSE

TRANSRIPTASE INHIBITORS(N tRTIs)

• Efavirenz(EFV), Etravirine(ETV), Nevirapine(NVP).

NON NUCLEOSIDE REVERSE

TRANSCRIPTASE INHIBITORS(NNRTIs)

Outline of the mechanism of how these drugs work

PREFERRED FIRST LINE ART IN TREATMENT(2013).

TDF + 3TC (or FTC) + EFV as a fixed-dose combination.

If TDF + 3TC (or FTC) + EFV is contraindicated or not available:• AZT + 3TC + EFV• AZT + 3TC + NVP• TDF + 3TC (or FTC) + NVP 

First-line ART for pregnant and breastfeeding women and ARV drugs for their infants

• Pregnant and breast feeding women = TDF + 3TC (or FTC) + EFV

• Infants of mothers who are receiving ART and are breastfeeding = Daily NVP or twice daily AZT

First-line ART for children younger than three years of age

• A LPV/r-based regimen = Less than 36 months of age. If not feasible, NVP based regimen.

 • Less than 3 years of age who have developed TB = ABC

+ 3TC + AZT

First-line ART for children three years and older (including adolescents).

• EFV is the preferred NNRTI for first-line treatment and NVP is the alternative

• For children infected with HIV three years to less than 10 years old (or adolescents less than 35 kg):• ABC + 3TC• AZT or TDF + 3TC (or FTC)

Second-line ART: what ARV regimen to switch to ?

After failure on a TDF + 3TC (or

FTC) -based first-line regimen = AZT

+ 3TC.

Combinations of ATV/r and LPV/r are the preferred

boosted PI options.

After failure of a first-line NNRTI = A

boosted PI + 2 NRTIs are recommended;

LPV/r is the preferred boosted PI

Second-line ART: what ARV regimen to switch to ?

After failure of a first-line regimen of ABC or TDF + 3TC (or FTC) = AZT +

3TC.

After failure of a first-line regimen containing AZT or

d4T + 3TC (or FTC) = ABC or TDF + 3TC (or

FTC)

After failure of a first-line LPV/r-based regimen,

children 3 years or older = NNRTI plus two NRTIs; EFV is

the preferred NNRTI

Third-line ART

THIRD LINE ART

New drugs with

minimal risk of cross-

resistance

Policies for third line ART .

Patients with no new ARV

options should continue with a

tolerated regimen.

MONITORING ART RESPONSE AND DAIGNOSIS OF TREATMENT FAILURE.

Viral load monitoring approach to diagnose

treatment failure.

If viral load not available, CD4 count

and clinical monitoring can be used.

WHAT IS POST EXPOSURE PROPHYLAXIS.

• Post-exposure prophylaxis (PEP) involves taking anti-HIV medications as soon as possible (within 3 days) after you may have been exposed to HIV to try to reduce the chance of becoming HIV positive.

• PEP must begin within 72 hours of exposure.• PEP is not 100% effective.

Go immediately.

DETERMINING EXPOSURE CODE

DETERMINING THE HIV STATUS CODE.

Post-exposure prophylaxis to prevent HIV infection

• For adults: Tenofovir combined with either Lamivudine (3TC) or Emtricitabine (FTC).

• For children: Zidovudine (AZT) and Lamivudine (3TC) with ritonavir-boosted lopinavir (LPV/r) recommended as the third drug choice.

Guidelines on post-exposure prophylaxis for HIV and the use of Cotrimoxazole prophylaxis

Infants

Start at 4-6 weeks and continue until proven otherwise.

Regardless of CD4 count and

symptoms until 5 years of age

1 – 4 years

Start if in stage II, III or IV or CD4

count is less than 25%.

Not given to children who show

severe adverse reactions.

Adults and adolescents

CD count below 350 or stage III

and IV

CD count not available; to the

ones with evident symptoms.

Pregnant women

Regardless of count or

symptoms

To be continued in feeding as well

REHABILITATIVE MANAGEMENT OF HIV AIDS.

Three primary goals of

rehabilitation are:

To increase or maintain functional capacity

To improve or maintain a person’s

quality of life, and

To decrease hospitalizations and increase

self care

REHABILITATIVE MANAGEMENT OF HIV AIDS.

• Impairments.•Activity Limitations.

•Participation Restrictions.

The model lays out

three categories, from micro level (body

part, individual) to macro level (community or society):

Preventive Management.

INTERNATIONAL AIDS PREVENTION INITIATIVE

Goals:• Provide a creative means for

remembrance and healing• Illustrate the enormity of the AIDS

epidemic• Increase public awareness of

AIDS• Assist with HIV prevention

education• Raise funds for community-based

AIDS service organizations

INTERNATIONAL AIDS VACCINE INITIATIVE• Currently there is no vaccine to prevent HIV AIDS.• Recent scientific discoveries and the RV144 trial.

NATIONAL RESPONSE TO THE PROBLEM OF HIV AIDS

The first case of AIDS was reported

in India in 1986. Soon after the government

introduced a high power committee in

1986 itself.

First acceleration(1992-1999) { The launch

of NACP 1 }.

From 1996 to 2006:NACP Phase

2 with focus on targeted

intervention.

During this phase, State AIDS control societies(SACS)

SACS Structure

Autonomous and Decentralized

Has on board representatives from key governing bodies

For better financial and operational efficiency, administrative and financial

powers are vested in the Executive Committee and the Programme Director.

Function of SACS are:

Medical and public health services

Communication and social sector services

Administration, planning, coordination, monitoring, evaluation

etc…

NATIONAL AIDS PREVENTION AND CONTROL POLICY 2002

• It was launched with the aim to bring AIDS transmission to zero level by 2007 by adapting the following strategies:• Prevention of further spread.• By providing an enabling socio economic

environment.• Improving services.

• NATIONAL HEALTH POLICY 2002 SET AN AIM FOR AIDS CONTROL SO AS ACHIEVE ZERO LEVEL GROWTH OF NEW HIV AIDS CASES BY 2007.

NATIONAL AIDS CONTROL PROGRAMME PHASE 3.2007-2012

Goals:• Prevention of new infections in high risk groups

and general population• Providing care, support and treatment to more

number of people living with AIDS.• Strengthening the infrastructure, resources and

man power resources.• strengthening the nationwide strategic

information management system.

saturation of coverage to high risk groups

scaling up intervention amongst general population

Improved treatment access

more number of people on ART

Establishing pediatric ART

financing of ART drugs

Integration of prevention with care, support and treatment.

Focus on children.

capacity building of SACS, NACO and DACS

TARGETS AND STRATEGIES:

6000 condom depots have been established

6000 village information centers have been established

red ribbon clubs have been established

mid media programs to be established and programmed.

mapping of high risk groups and migrants

development of training modules

Progress under NACP3

XII FIVE YEAR PLAN 2012-17. 

The government approved a budget of

8632.77 crores for NACP phase 4.

80% reduction in new cases in high

prevalence rates and 60% in low

prevalence rates.

Comprehensive care, support and treatment

for PLHA and strengthening the

program initiatives.

intensifying and consolidating quality prevention services

and enhancing access, quality and coverage

increasing access and promoting

innovative sustainable mechanisms

expanding services for high risk and low

risk groups and strengthening

institutional capacities

NATIONAL AIDS CONTROL PROGRAMME IVStrategies under NACP IV:

Target intervention for

migrants

Target intervention by

NACO and SACS

Non TI programs by NGOs

Work place intervention

Target intervention for

truckers

Increased cover of LDTs

Operationalize national

network of truckers

Ensure universal access to services

Strengthen the quality of

information shared

Target intervention amongst female sex workers:

• Increased coverage in north India• Improving quality of intervention• active participation and sharing of responsibility• building ownership, leadership and accountability of

SACS• reaching out deeper• addressing trafficking and violence• convergence of prevention, care support and treatment• development of district, state and community level

resources

Target intervention

amongst Hijras and

Transgender

By providing a minimum package of

condoms and lubes

services for HIV +ve ones

sexual health services

providing a enabling

environment

by targeted media

campaigns

Target intervention towards MSM (Men who have sex with men)

Towards zero new cases amongst MSM by the end of 2017, and universal access to prevention, care, support and treatment by: 

• Reaching a diverse group of MSM• By providing a comprehensive package of prevention,

care, support and treatment• to create and sustain enabling environment• to mobilize and strengthen their communities to

contribute to national responses

STD control programme was launched with the objectives to:

• Reduce STD cases and thereby reduce HIV cases• prevent short term as well as long term morbidity and

mortality due to AIDS and STDsThe strategies are as follows:

• develop adequate and effective program management• promote IEC activities for the prevention and

transmission• make adequate arrangements for the adequate and

comprehensive case management• increasing access to health care• creating facilities for diagnosis and treatment• By adapting a syndromic approach

Laboratory services launches by NACO: National external quality assessment scheme(NEQAS)

Objectives:• monitoring lab performances and monitoring quality

levels• establishing intra laboratory comparability• promoting high standards• encouraging use of standard quality instruments and

reagents• influencing reliability• identifying common error• facilitate information exchange• supporting accreditation• Education

NEQAS set up 4 tiers of laboratories:

1) Apex in national AIDS research institute Pune

2) 13 national reference labs

3) 118 state level labs

4) district level labs

VOLUNTARY COUNSELLING AND TESTING. Objectives of Voluntary counselling and testing (VCT)

• To provide the client with information on the HIV test, its benefits and the risks involved.

• The aim is to have the informed consent of the client before the test and to help the client gain a better understanding of the test results.

• To provide the client with background information on HIV/AIDS infection, modes of transmission, preventive methods, treatment and care.

• To assess the risk of HIV infection in the client.• To encourage and maintain a safe behaviour to avoid

future infection and/or to prevent the further spread of HIV (e.g. through safe sex and changing drug injecting practices).

• To help the client to handle possible emotional reactions related to the HIV test results (e.g. grief, anger, fear and denial).

• To discuss courses of action adapted to each client, his family needs and circumstances.

The main functions of ICTCs are to:

• Early detection• provision of basic information on AIDS• link people with other services such as prevention, care

and treatment services

Types of ICTCs:

• FIXED FACITLITY: Stand alone and facility integrated• MOBILE ICTCs.

To offer HIV test to all pregnant

women.

To reduce PTCT to less than 5%

To provide education and planning services

to HIV –ve women.

To provide access to family planning.

To link all exposed mother and babies to care, support and treatment at the earliest

PPTCT( PREVENTION OF PARENT TO CHILD TRANSMISSION) PROGRAMME

strengthening the

national blood

transfusion programme

ensuring adequate supply of

blood to all centers

ensuring safety

developing facilities

strengthening quality control

undertaking research on

blood transfusion techniques

effective management

and monitoring of

blood transfusion techniques

SAFE BLOOD PROGRAMME.

Technical assistance to companies to manufacture condoms

strengthening the marketing structure

Strengthening the management ability of private organizations

collaborating with the existing programmes

strengthening program management

supporting and strengthening the ICMR and other research institutes for undertaking research on condoms.

CONDOM PROGRAMME