+ HIV: Clinical Manifestations and Treatment. Dr Denise Borg 24 th November 2014

Transcription

1 HIV: Clinical Manifestations and Treatment Dr Denise Borg 24 th November 2014

2 HIV: Global Statistics

3

4

5 HIV Cases in Malta YEAR OF DIAGNOSIS NUMBER

6 Local Statistics: Malta February % 0% 30% 70% Males Females Total Number of patients: 198

7 Malta: HIV positive patients by gender and nationality Feb 2012 Males Females Total Maltese Foreigners

8 Malta: HIV Patients by Nationality 12% 0% 33% 55% Maltese Africans Other Foreigners

9 HIV Viral structure and genome Single stranded RNA virus Retrovirus Two different types exist: HIV Type 1 HIV Type 2

10 HIV Lifecycle

11 What happens then? The amount of HIV virus in the body increases, resulting in a detectable HIV viral load in the blood. The level of CD4 cells in the blood decreases, making the patient more susceptible to certain infections

12 HIV: Modes of Transmission

13 Malta: HIV Modes of Transmission 34% 4% 1% Vertical Transmission Heterosexual 61% Homosexual Blood Products

14 HIV transmission: Sexual Contact Risk of HIV from sexual exposure varies with: sexual practices skin lesions mucosal trauma presence of other STD s HIV viral load

15 HIV Transmission: Intravenous Drug Use Sharing needles, syringes, rinse water or other equipment used to prepare injecting drugs carries a risk of transmission of HIV

16 HIV Transmission: Mother to Child RiskFactorsforMTCT: High maternal viral load LowmaternalCD4count AIDSinmother Normal vaginal delivery if HIV viral load is detectable Premature ROM >4hrs Pre-term infants <37 wks Breastfeeding

17 HIV Transmission: Mother to Child Without treatment ~25% of HIV positive mothers will transmit HIV to their child This can be reduced to 0.5-1% if the necessary interventions are taken: Treat HIV positive pregnant mothers Avoid vaginal delivery unless HIV viral load is undetectable Avoid breastfeeding Give the child treatment for a few weeks

18 HIV: Stages of Infection

19 HIV: Acute Infection Fever Rash Lymphadenopathy Sore throat Myalgias, arthralgias Headache Nausea, vomiting, diarrhoea

20 CD4 Count versus HIV Viral Load

21 HIV: Clinical Latency Also called asymptomatic HIV infection HIV positive patients experience no HIV related symptoms, or only mild ones People on HAART may live with clinical latency for several decades In people not taking HAART clinical latency lasts an average of 10 years

22 CD4 Count versus HIV Viral Load

23 AIDS: Acquired Immune Deficiency Syndrome Occurs when either CD4 count is less than 200 cells/mm 3 or else patient develops one or more opportunistic illnesses regardless of CD4 count HIV positive patients may have the following symptoms: Rapid weight loss Recurring fever or profuse night sweats Unexplained lethargy Lymphadenopathy Persistent diarrhoea Sores of the mouth, anus or genitalia Pneumonia Skin rashes Memory loss, depression and other neurological disorders

24 CD4 Count versus HIV Viral Load

25 AIDS Defining Illnesses: Opportunistic Infections Candidiasis CMV retinitis Pneumocystis jiroveci pneumonia Kaposi sarcoma Cerebral Toxoplasmosis Cryptococcosis; extrapulmonary Mycobacterium tuberculosis Atypical Mycobacteria (extrapulmonary or disseminated)

26 Candidiasis OccursataCD4count<100cells/mm 3 Patient complains of pain and difficulty on swallowing Treatment is with an antifungal ex: fluconazole

27 CMV Retinitis Caused by cytomegalovirus Occurs with CD4 count <50 cells/mm 3 Patient complains of visual problems, can become blind if left untreated Treat with HAART and antiviral agents such as valgancyclovir

28 Pneumocystis JiroveciPneumonia OccurswithaCD4count<200 cells/mm 3 Patient presents with dry cough, fever and exertional dyspnoea Chest X-ray: Bilateral perihilar shadowing Treat with co-trimoxazole and steroids

29 Kaposi sarcoma Erythematous to violaceous lesions on the skin Tumour caused by infection with human herpes virus 8 Can present with cutaneous lesions +/-internal involvement

30 Cerebral Toxoplasmosis Caused by Toxoplasma gondii Associated with CD4 count <100cells/mm 3 Patients complain of neurological symptoms such as weakness, altered sensation, seizures, confusion etc Treatment is with pyrimethamine and sulfadiazine

31 Cryptococcosis Caused by Cryptococcus neoformans Associated with CD4 count <100 cells/mm 3 Patient presents with headaches, neck stiffness, fever, altered mental status or focal neurological signs Treatment involves liposomal amphotericin, flucytosine and fluconazole used alone or in combination

32 Mycobacterium Tuberculosis HIV patients have an increased incidence of TB; both primary infection and reactivation TBcanbeeither: Pulmonary TB Extrapulmonary TB Disseminated/ Miliary TB

33 HIV: Treatment In 1987, the first anti-retroviral agent, AZT, was used in the treatment of HIV. Using one drug alone didn t prove to be very effective in controlling HIV Over the years, other drugs were developed and we now use a combination of drugs to treat HIV HAART (Highly Active Antiretroviral Treatment)

34 HAART: Aims of Treatment Prolongation of life and improvement in quality of life ReduceHIVviralload Increase CD4 count

35 HIV: Monitoring Treatment Measure: HIVviralload CD4count In the clinic this is done every 4 months, if patient is stablethiscanbedoneevery6months.

36 HAART: Highly Active Anti- Retroviral Treatment NRTI s: Nucleoside reverse transcriptase inhibitors NNRTI s: Non-nucleoside reverse transcriptase inhibitors PI s: Protease inhibtors Entry inhibitors: CCR5 antagonists Fusion inhibitors Integrase inhibitors Combination drugs: where 2 or 3 drugs are combined together in 1 tablet

37 HAART: Mechanism of Action

38 HAART: Indications for starting treatment Treatment is recommended in: HIVpositivepatientswithCD4countlessthan350/mm 3 Symptomatic HIV disease(including tuberculosis) Patients with AIDS Pregnant HIV positive women HIV positive patients who have conditions (likely or possibly) associated with HIV such as HIV associated kidney disease, HIV associated neurocognitive impairment, Hodgkin s lymphoma and HPV associated cancers Hepatitis B co-infection requiring treatment

39 Relative indications to start treatment Consider treatment in the following group of patients: Hepatitis B co-infection not requiring treatment Hepatitis C co-infection To reduce viral transmission Other non-aids defining cancers requiring chemo +/- radiotherapy Autoimmune disease: otherwise unexplained High risk for cardiovascular disease (>20% estimated 10 year risk) or history of cardiovascular disease Primary HIV infection

40 Malta: Patients on treatment in % 0% 6% 66% Maltese Foreigners Immigrants Total Number of Patients: 110

41 Problems with HAART: Adherence Oneofthemajorproblemsinourdailypractice It s importance cannot be overstressed HAART must be taken daily, no doses should be missed and strict adherence totimingisvital If not HIV virus will become resistant to medications and treatment fails

42 Problems with HAART: Side Effects Gastrointestinal (nausea, vomiting, diarrhoea) Rashes Liver toxicity Renal toxicity CNS side-effects: drowsiness, hallucinations, depression Anaemia Peripheral neuropathy Lipodystrophy

43 Post-exposure prophylaxis

44 THANK YOU