HIV Lecture. Anucha Apisarnthanarak, MD Division of Infectious Diseases Thammasart University Hospital

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1 HIV Lecture Anucha Apisarnthanarak, MD Division of Infectious Diseases Thammasart University Hospital

2 End-2001 global estimates for children and adults People living with HIV/AIDS New HIV infections in 2001 Deaths due to HIV/AIDS in million 5 million 3 million

3 Adults and children estimated to be living with HIV/AIDS as of end 2001 North America Caribbean Latin America 1.4 million Western Europe North Africa & Middle East Sub-Saharan Africa 28.1 million Eastern Europe & Central Asia 1 million East Asia & Pacific 1 million South& South-East Asia 6.1 million Australia & New Zealand Total: 40 million

4 Estimated number of adults and children newly infected with HIV during 2001 North America Caribbean Latin America Western Europe North Africa & Middle East Sub-Saharan Africa 3.4 million Eastern Europe & Central Asia East Asia & Pacific South & South-East Asia Australia & New Zealand 500 Total: 5 million

5 About new HIV infections a day in 2001 More than 95% are in developing countries 2000 are in children under 15 years of age About are in persons aged 15 to 49 years, of whom: almost 50% are women about 50% are year olds

6 HIV/AIDS Estimation in Thailand at the end 2001 People living with HIV/AIDS People living with AIDS New HIV infections in 2001 Deaths due to HIV/AIDS in ,000 67,000 25,000 55,000

7 HIV Infection in Thailand Living w/hiv and AIDS Cumulative HIV New HIV 1985 thousands of HIV infections

8 Number of STD cases and condom use rate among male & CSW ( ) thousands 300 male Percent condom use prostitute Condom use rate

9 HIV Prevalence among Injecting Drug Users at Treatment Clinics, Thailand % Jun-89 Dec-89 Jun-90 Dec-90 Jun-91 Dec-91 Jun-92 Dec-92 Jun-93 Dec-93 Source: Sentinel Serosurveillance, Division of Epidemiology, MoPH Remark: Switching from bi-annually (June and December) to annually in June since 1995 Jun-94 Dec-94 Jun-95 Jun-96 Jun-97 Jun-98 Jun-99 jun00 Year

10 HIV Prevalence Among Pregnant Women, Male Conscripts, Donated Blood:Thailand % Conscripts (age 21) Pregnant women Donated blood Jun-89 Dec-89 Jun-90 Dec-90 Jun-91 Dec-91 Jun-92 Dec-92 Jun-93 Dec-93 Jun-94 Dec-94 Jun-95 Dec-95 Jun-96 Jun-97 Jun-98 Jun-99 Jun-00 Jun-01 Source: Sentinel Serosurveillance, Division of Epidemiology, Ministry of Public Health. Remark: Switching from bi-annually (June and December) to annually in June since 1995 Conscript data in November of each year since 1995 were not shown here Month/Year

11 Reported AIDS Cases by year, Thailand ,676 6,949 13,923 20,686 24,709 26,817 27,304 26, Number of cases 30,000 25,000 20,000 15,000 10,000 5, Source: Division of Epidemiology, MOPH, Thailand data as of December 31, 2001 Delay effec

12 Trend of AIDS incidence by region North Central South Norteast

13 Distribution of Reported AIDS cases by Age-group of Diagnosis in Thailand, September January Male Female unk.

14 Transmission Sexual intercourse, anal and vaginal Persons at higher risk of heterosexual transmission ulcerative STD multiple sex partners partner of IVDA male-to-female is 7 to 9 x more efficient partner of uncircumcised males

15 Transmission Casual contact is NOT a significant risk Parenteral transmission contaminated blood (1%) IVDA-needle sharing occupational risks (0.3%) perinatal infection (>90%of pediatric case) breast feeding

16 Mode of HIV Transmission in Thailand Sexual Transmission 83.10% IDU 4.97% Blood products 0.03% MTCT 4.87% Others 0.01% Unknown 7.15%

17 Pathogenesis

18 HIV Infection via Mucosa Intact mucosa? R5 virus infects dendritic cells Transport of virus to regional LN Transmit to CD4+ T cells in regional LN Walker et al. NEJM 1998

19 Dendritic Cells and HIV Infection Steinman RM. Cell 2000:100:

20 Dendritic Cells (DCs) It can stabilize HIV-1 for more than 4 days, because binding to DC-SIGN protects HIV from proteases that are present in plasma. This then likely allows for transport of the virus to regional lymph nodes, where infection can be propagated further. van Kooyk et al 2001

21 HIV Infection Lymph nodes Viremia Dissemination to other organs Brain Spleen Gut Within few days Walker et al 1998

22 HIV-1 Life Cycle

23 Pathogenesis

24 Clinical Presentation Primary HIV infection-viral syndrome or mononucleosis-like illness fever, pharyngitis, adenopathy, rash A high viral load >50,000 copies/ml An immune response develops but will not eliminate viral replication HIV is trapped by follicular dendritic cells and replicates in germinal center

25 Natural Course of HIV Infection and Host Responses Relative Levels CD4+ T-cellsAnti-HIV Ab HIV-CTL+CD8 activity Plasma HIV Viremia Months Years After HIV Infection Acute HIV infection Symptom AIDS-related illness

26 Clinical Presentation

27 ELISA, EIA OraSure: oral collection device OraQuick Home Access False-negative Positive ELISA

28 Western Blot Test Is the confirmatory test for final diagnosis looks for the glycoprotiens of the HIV virus (i.e., gp 120, gp 41)

29 Detection Markers Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) Measures the amount of HIV-RNA viral load in copies/ml The test used to develop a baseline viral load and for monitoring therapeutic response to treatment

30 Natural Course of HIV Infection and Common Complications CD4+ cell Count Acute HIV infection syndrome Asymptomatic TB TB HZV OHL PPE OC CMV, MAC PCP CM Months CD4+ T cells Years After HIV Infection VL Relative level of Plasma HIV-RNA

31 Five Most Common Opportunistic Infections Thailand Tuberculosis (27.4%) Pneumocystis carinii (19.5%) Cryptococcosis (16.7%) Candidiasis Recurrent Pneumonia (5.3%) (3.7%) Source: Epidemiology Section, Ministry of Public Health

32 Approach for Opportunistic Infections 1) Symptoms 2) Onset of Symptoms 3) CD 4 cell count 4) Prophylactic medications 5) Compliance to prophylactic medications 6) Specific pattern (CXR) 7) Diagnostic Microbiology

Program to control HIV/AIDS

90-90-90 Program to control HIV/AIDS Hamid Sharifi Associate Professor in Epidemiology [sharifihami@gmail.com] 1 Targets for ending the AIDS epidemic 2 New HIV infections in low- and middle-income countries,