HIV/AIDS pts Flashcards
discovery of HIV
The human immunodeficiency virus (HIV) was first
isolated in 1983 and was retrospectively identified as
the cause of acquired immunodeficiency syndrome
(AIDS; reported 1981)
HIV family
HIV is a non-transforming retrovirus of the lentivirus subfamily.
* Two main subtypes, HIV-1 and HIV-2, based on
genetic and antigenic differences, and many strains of
each
more common form of HIV
HIV-1 being more common (overall) particularly in
sub-Saharan Africa, while HIV-2 is more prevalent in
West Africa and associated with slower disease course
Since the onset of the worldwide pandemic, more than ___________-people have been infected with HIV, of whom approximately _________ have died because of
AIDS.
Since the onset of the worldwide pandemic, more than 70,000,000 people have
been infected with HIV, of whom approximately 35,000,000 have died because of
AIDS.
how many new HIV infections per year
2.7mil
what region has the highest % of the total HIV infected individuals
eastern/south africa (54%)
- Approximately _________ people in the U.S. are living with HIV today.
- Approximately 1.2 million people in the U.S. are living with HIV today.
CDC estimate for new HIV infections per year in US
38,000
male vs female rate of infection in the US
the rate for males (22.1) was 5 times the rate for females (4.8)
HIV infection by age groups
By age group, in 2018, the number of new HIV diagnoses was highest among people aged 25-44
single greatest risk factor of HIV
male-to-male sexual contact remains the
largest single risk facto
rise in HIV infection in what demographic
greater proportion of cases arising in blacks/African Americans, Hispanics/Latinos, females, and heterosexuals.
* Although blacks/African Americans represented
only about 14% of the United States population,
they accounted for 44% of new HIV infections.
what region is HIV most prevalent in the US
south
body fluids for HIV transmission
- Blood, semen, breast milk, and vaginal secretions are the main fluids that have been shown to be associated with transmission of the virus. HIV can also be found in tears, saliva, cerebrospinal fluid, amniotic fluid, and urine
How are body fluids used to transmit HIV
Transmission of HIV is by exchange of infected bodily fluids predominantly through intimate sexual contact and by parenteral means. (Sharing needles and blood transfusions, organ transplants etc.)
where can HIV infection occur? what can aid in this?
- HIV infection can occur through oropharyngeal, cervical, vaginal, and gastrointestinal mucosal surfaces, even in the absence of mucosal disruption.
- Infection is particularly aided by the presence of other sexually transmitted diseases that can produce mucosal ulceration and inflammation.
The most common method of sexual transmission in the United States is:
The most common method of sexual transmission in the United States is anal intercourse in men who have sex with men (MSM), in whom the risk of HIV infection is 40 times higher than in other men and in women
heterosexual transmission
Heterosexual transmission (male to female or female to male) is the second most common form of transmission in the United States but accounts for 80% of the world’s HIV infections.
transmission thru needles
third most common route
The risk of transmission from a blood transfusion is estimated to be less than:
less than 1 in 1 million because of current screening measures
children/casual contact transmission
Children (< 13 yr) usually through perinatal exposure (mother to infant).
Casual contact has not been demonstrated as a means of transmission.
HIV oral transmission
- Transmission by oral fluids is somewhat controversial and rarely documented.
- Saliva contains a number of HIV inhibitory factors, which appear to reduce the ability of the virus to infect its target cells.
- The presence of erosions, ulcerations, and hemorrhagic inflammatory pathoses (e.g., gingivitis, periodontitis) may predispose an individual to oral transmission.
HIV structure
enveloped single stranded RNA virus
HIV key antigenic components
gag, pol, env
Gag
(HIV ag)
processed to matrix and other core proteins to determine core
p17, p24 (capsid), p7
Pol
(HIV)
reverse transcriptase, RNase H and integrase functions
p66/51 (RT), p32 (IN), p11 (PR)
other HIV antigens
two regulatory proteins (Tat and Rev) that are essential for viral replication, and four accessory proteins (Nef, Vif, Vpu, Vpr).
HIV cell cycle stages
Entry>Replication> Release
HIV entry
- HIV primarily infects cells with CD4 cell-surface
receptor molecules (CD4+ T helper lymphocytes
mainly) at the site of HIV entry. - Infection is aided by Langerhans cells in mucosal
epithelial surfaces which can become infected
delivering HIV to underlying T cells, ultimately
resulting in dissemination to lymphoid organs - The virus uses CD4+ cells to gain entry by fusion
with a susceptible cell membrane or by
endocytosis (with the help of co-receptors
CXCR4 and CCR5) - The probability of infection depends on both the
number of infective HIV virions in the body fluid
which contacts the host and the number of cells
with appropriate CD4 receptors available at the
site of contact.
HIV entry picture
CD4+ cells capable of being infected
T-helper lymphocytes, Langerhans,
macrophages, and some dendritic cells
HIV replication
- Once within the cell, the viral particle uncoats from its spherical envelope to release its RNA.
- The enzyme product of the pol gene, a reverse transcriptase that is bound to the HIV RNA, synthesizes linear double-stranded cDNA that is the template for HIV integrase.
- It is this HIV proviral DNA which is then inserted into the host cell genomic DNA by the integrase enzyme of the HIV.
HIV replication diagram
HIV release
- Just before the budding process, HIV protease cleaves Gag proteins into their functional form which get assembled at the inner part of the host cell membrane, and virions then begin to bud off.
- Nucleocapsid (NC) protein interacts with the RNA within the capsid
- Capsid (CA) protein surrounds the RNA of HIV
- Matrix (MA) protein surrounds the capsid and lies just beneath the viral envelope.
- Release of HIV from the host cell occurs in several steps.
- The cells HIV selects for replication are soon “swell and burst” by caspase-3-mediated apoptosis (~5%), the remaining >95% of quiescent lymphoid CD4 T- cells die by caspase-1-mediated pyroptosis triggered by abortive viral infection.
- The spectrum of HIV disease changes as CD4+ cell count declines.
Seroconversion
transition from the point of viral infection to when antibodies of the virus become present in the blood (circulating antibodies).
The CDC Staging of HIV Infection in Adults and Adolescents
stage 1, 2, 3 (full blown AIDS)
stage 1
timeframe and symptoms
- During the first 2 to 6 weeks after initial infection with HIV, ~70% of patients develop an acute flulike syndrome marked by viremia (acute seroconversion syndrome) that may last 10 to 14 days (sometimes up to 4 weeks). Others may not manifest this symptom complex
stage 1 symptoms
how many actually seek care?
Symptomatic persons often develop mononucleosis-like symptoms: lymphadenopathy, fever, pharyngitis, weakness, diarrhea, nausea, vomiting, myalgia, headache, weight loss, and a skin rash (roseola-like or urticarial). Only an estimated 20% of symptomatic persons seek medical attention
CD4 count in stage 1
A concomitant transient fall in CD4+ cells occurs along with high titers of plasma HIV, but patients do not develop evidence of immunosuppression (>500 cell/ml; CD4+ cell count tend to return toward normal levels after acute symptoms
Ab development in HIV stage 1
CD4 drop is usually followed by developing antibodies (anti-gag, anti-gp120, anti-p24) between weeks 6
and 12. A few may take 6 months or longer to achieve seroconversion particularly in patients without acute symptoms. (6 weeks – 6 months, 97% within the first 3 months of infection)
The severity of the initial acute infection with HIV (i.e., level of viremia) is predictive of:
The severity of the initial acute infection with HIV (i.e., level of viremia) is predictive of the course the infection will follow. Generally, the longer the acute infection lasts the earlier patients develop AIDS
Latent asymptomatic period
how long can it last
continuum of stage 1; asymoptomatic stage 2
Can last up to 8–10 years.
latent asym period viral activity
- The virus disseminates throughout lymphoid tissue, incubates, replicates (several thousand copies), and alters many physiologic processes, resulting in hyperimmune activation, persistent inflammation, and impaired gut function and flora.
- Evolution of the virus within its host to generate closely related yet distinct mutant viruses that serve to evade the surveying immune response and circulating
antibodies
latent asym CD4 count and IS ability
There is a progressive decline in immune function evident as progressive depletion of CD4+ cell count (CD4+ lymphocytes >500 cells/μL) & slow but usually progressive increase in viral load
non-progressors of the latent asym period
<1% are non-progressors and maintain a low viral load.
* Silent clinically except for persistent generalized lymphadenopathy (Up to 70% of patients).
stage 2 can last:
1-3 yrs
stage 2
s/s progression?
CD4?
viral load?
plattets?
- Signs and symptoms increase as the CD4+ count drops below 500 cells/μL and approaches 200 cells/μL (often between 200 and 300/μL)
- Viral load continues to increase.
- Platelet count may decrease in about 10% of patients
stage 2 s/s?
Any or a combination of the following:
* Persistent generalized lymphadenopathy
* Fungal infections
* Vaginal yeast and trichomonal infections
* Oral hairy leukoplakia (OHL)
* Herpes Simplex Viruses (HSV-1 & HSV-2)
* Herpes Zoster (VZV)
* HIV-related retinopathy
* Constitutional symptoms: fever, night sweats, fatigue, diarrhea, weight loss, weaknes
stage 3
susceptiable to?
AIDS
* When the CD4+ count drops to below 200 cells/μL (also high viral load) or documentation of an AIDS-defining condition, the person has AIDS and is susceptible to opportunistic infections and maliganacies
- Opportunistic infection(s) of AIDS
Pneumocystis jiroveci pneumonia, cryptococcosis, tuberculosis, toxoplasmosis, histoplasmosis, etc
plattets and PMN with AIDs
may be low
- CD4+ cell count <50/μL at high risk for:
lymphoma and death
malignancies associated with AIDS
Kaposi sarcoma, Burkitt lymphoma, non-
Hodgkin lymphoma, primary CNS lymphoma, invasive
cervical cancer, carcinoma of rectum, slim (wasting)
disease
AIDS death usually due to
wasting, opportunistic infection, or malignancies.
CD4/8 ratio
CD4/CD8 ratio reflects immune system health. A normal ratio is between 1 & 4.
CD4/8 counts with HIV infection
when are these done?
CD4+ and CD8+ cell counts should be performed at the time of HIV diagnosis and then every 3 to 4 months
types of HIV testing
- Nucleic acid tests (NATs)
- Antigen/antibody tests
- Antibody tests
- HIV tests are typically performed on blood or oral
fluid. They may also be performed on urine
NA HIV tests:
* Detect?
* Polymerase chain reaction (PCR)–based assays of the viral RNA is performed to determine if?
*** Detect HIV when?
* routinely used?
* *The greatest viral load is found when?
- Detect the actual virus in the blood.
- Polymerase chain reaction (PCR)–based assays of the viral RNA is performed to determine if a person has HIV or the viral load in the blood (i.e., degree of viremia)
and monitor response to therapy.
* Detect HIV sooner (superior) than other types of tests. - More expensive and not routinely used.
- Detection ranges are from 40 copies/mL to more than 750,000 copies/mL. The greatest viral load is found during the first 3 months after initial infection and during late stages of the disease
Ag/Ab tests for HIV
- Detect both HIV antibodies and antigens in blood
samples. - In HIV-infected individuals, p24 is produced even before antibodies develop.
- Antigen/antibody tests are recommended for testing
done in labs and are now common in the United
States. - This lab test involves** drawing blood from a vein.
There is also a rapid antigen/antibody test available
that is done with a finger prick.** - E.g., Abbott has developed a combination assay, the ARCHITECT HIV Ag/Ab Combo assay (Abbott Laboratories, Abbott Park, IL), that can simultaneously detect the combined presence of HIV antigens (p24 antigen) and antibodies to HIV. This test is important for diagnosing HIV infection in the acute phase of the disease when antibodies are not yet present and for ongoing monitoring of patients.
Antibody tests for HIV
- Only detect antibodies to HIV in blood or oral fluid.
- In general, antibody tests that use blood from a vein can detect HIV sooner after infection than tests done with blood from a finger prick or with oral fluid.
- Most rapid tests and the only currently approved HIV self- test (OraQuick) are antibody tests.
- Enzyme-linked immunosorbent assay (ELISA) testing for HIV in saliva is 98% sensitive in detecting antibodies to **HIV
OraQuick
- Upper and lower gums are swabbed with the test stick.
- Test stick is inserted into the kit’s test tube (vial) which
contains a developer solution. - 20-40 minutes wait time before reading the test result.
- 92% sensitivity.
*** Additional testing should be done in a medical setting toconfirm the test result: - Positive.
- Negative and exposure may have been within the
previous three months.**
current practice for HIV exposure in medical setting
Current practice in medical setting is to screen first ELISA. If the results are positive, a second ELISA is performed (due to high rate of false positive). All positive results are then confirmed with Western blot analysis. This combination of tests is accurate more than 99% of the time and the patients are considered
potentially infectious
what do positive ELISA and western blot indicate
exposure to HIV
dental use of HIV screening
National surveys conducted on American general dentists predicted their willingness in implementing oral HIV rapid testing during dental visits.
* Although opposed by challenges of cost, licensing, and patient acceptance, potential models for integrating HIV screening into routine dental practice have been proposed representing a step forward towards early detection of the disease.
The natural history of human immunodeficiency virus infection diagram
Antiretroviral Medications (ARVs)
Highly active antiretroviral therapy, now known as combined antiretroviral therapy (cART) or ART, refers to the antiretroviral medications (ARVs) prescribed as an HIV drug regimen for the prevention and treatment of HIV/AIDS.
Guidelines developed for effective drug therapy to treat HIV/AIDS in most patients living
with HIV/AIDS incorporate:
a three-drug regimen as a standard for long-term therapeutic effectiveness against the virus
ARVs selected as part of a regimen are tailored to?
pt specific needs,taking into consideration the patient’s comorbidities or previous ART for example
life expectency with ART tx
The life expectancy of an HIV-infected individual appropriately treated with ART is now estimated to be nearly that of the general population, both in developed and developing countries, although it also is estimated to be about 1.7-fold higher than in healthy people with no comorbid conditions.
current guidelines for when ART tx started
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.
Patients who respond to therapy generally show:
increase in CD4+ count in the range of 50 to 150 cells/μL per year and viral loads of less than 5 copies/mL.
Virologic suppression and virologic failure
Virologic suppression is defined as less than 48 copies/mL, and virologic failure is defined as a
confirmed viral load of greater than 200 copies/mL in the presence of ART
ART monitoring
- Patients who are taking ART medications must be closely monitored for drug effectiveness (which often wanes over time), development of antiviral resistance, drug toxicity, and/or drug interactions.
- Antiviral resistance testing is recommended when treatment is failing.
- Some important toxicities include hyperlactemia, mitochondrial dysfunction, peripheral neuropathy, hepatotoxicity, and lipodystrophy.
Pre-exposure prophylaxis
- A way for people who do not have HIV but who are at very high risk of getting HIV to prevent HIV infection by taking a pill every day.
- The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV.
When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection
Management of Infants Born to Women with
HIV Infection
- All newborns who were exposed perinatally to HIV should receive postpartum ARVs to reduce the risk of perinatal transmission of HIV.
The average dental practice is predicted to encounter _
____ patients infected with HIV per year
at least 2