ACQUIRED IMMUNO-

DEFICIENCY
SYNDROME (AIDS)
PREPARED BY:
AHMED I. ALBAHBHANI
PRESENTED TO:
DR. FOUAD AL-ISSAWI
2017
OUTLINES

• History
• Epidemiology
- Magnitude of the problem
- Agent factor
- Host factor
- Environmental factor
• Modes of transmission & portal of entry
• Pathology & pathogenesis
• Clinical features, complications & treatment
• Prevention, control & immunization
HISTORY
HISTORY

• 1959: In 1986, a retrospective analysis of frozen blood samples from a

variety of African countries identifies an unnamed African man living in
Kinshasa, in the Democratic Republic of the Congo, as having HIV. This is
probably not the first case of HIV ever – there are numerous cases of likely
HIV infection based on symptoms and AIDS-defining illness – but this is the
earliest where a blood sample can verify infection.
HISTORY (CONT.)

• 1981: This New York Times headline, published on 3 July 1981, marks the first mainstream
press coverage of an HIV-related issue. It chronicles the diagnosis of Kaposi’s Sarcoma - “a
rare and often rapidly fatal form of cancer” - in the gay community across several US cities.
The article is based on information from the US Centers for Disease Control (CDC) Morbidity
and Mortality Weekly Report (MMWR), released on the same day.
• In September, the CDC used the term “AIDS” (acquired immune deficiency syndrome) for the
first time, describing it as
“a disease at least moderately predictive of a defect in cell mediated immunity, occurring in a
person with no known case for diminished resistance to that disease.”
HISTORY (CONT.)

• In May 1983, two doctors at the Pasteur Institute in France, Luc Montagnier and
Françoise Barré-Sinoussi, report the discovery of a new retrovirus called
Lymphadenopathy-Associated Virus (or LAV) that could be the cause of AIDS –
the virus later known as HIV. While they do not specifically state that LAV is the
cause of AIDS, the isolation of LAV is critical for definitively confirming this.
• By the end of 1984, there had been 7,699 AIDS cases and 3,665 AIDS deaths in
the USA with 762 cases reported in Europe.
 HISTORY (CONT.)

• Ryan White, a teenager from Indiana, USA who acquired AIDS

through contaminated blood products used to treat his
haemophilia was banned from school.
• 1 December 1988 the first world AIDS day is held
• 1991 red ribbon is created as a symbol of HIV awareness
HISTORY (CONT.)

• 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 (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.
• In 1999, the WHO announced that AIDS was the fourth biggest cause of death worldwide and
number one killer in Africa. An estimated 33 million people were living with HIV and 14
million people had died from AIDS since the start of the epidemic.
http://timeline.avert.org/
EPIDEMIOLOGY
- MAGNITUDE OF THE PROBLEM
- AGENT FACTORS
- HOST FACTORS
- ENVIRONMENTAL FACTORS
 MAGNITUDE OF THE PROBLEM
• Worldwide :
- Estimates of the size and course of the HIV epidemic are updated every year
by UNAIDS and WHO.
- Since the beginning of the epidemic, more than 70 million people have been
infected with the HIV virus and about 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.
MAGNITUDE OF THE PROBLEM (CONT.)

- An estimated 0.8% [0.7-0.9%] of adults aged 15–49 years worldwide are

living with HIV, although the burden of the epidemic continues to vary
considerably between countries and regions. Sub-Saharan Africa remains
most severely affected, with nearly 1 in every 25 adults (4.4%) living with
HIV and accounting for nearly 70% of the people living with HIV
worldwide.
MAGNITUDE OF THE PROBLEM (CONT.)

- National: HIV and AIDS case registration started in 1988 and up to the end
of November 2014, 84 HIV cases were reported in the national registry, of
which 69 developed AIDS with the largest share of registered HIV cases was
in the age range 15-49 years.
http://palestine.unfpa.org/sexual-reproductive-health#sthash.Lp09fkev.dpuf
AGENT FACTOR

• Agent : HIV belongs to a class of viruses called retroviruses. Two types have been
identified : Type-1 (HIV-1) and Type-2 (HIV-2). Retroviruses are RNA (Ribonucleic
Acid) viruses, and in order to replicate (duplicate), they must make a DNA
(Deoxyribonucleic Acid) copy of their RNA. It is the DNA genes that allow the virus
to replicate. Like all viruses, HIV can replicate only inside cells, commandeering the
cell’s machinery to reproduce. Only HIV and other retroviruses, however, once inside
a cell, use an enzyme called reverse transcriptase to convert their RNA into DNA,
which can be incorporated into the host cell’s genes.
AGENT FACTOR (CONT.)

• Reservoir of infection: The only reservoir are Humans - cases and carriers.
Once a person is infected, the virus remains in the body life long. Since
symptoms takes years to manifest, the carrier can infect other people for
years.
• Infective materials: The virus has been found in greatest concentration from
blood, semen and CSF. Lower concentrations in tears, saliva, breast milk,
urine, and cervical and vaginal secretions.
AGENT FACTOR (CONT.)

• Period of infectivity : Presumed to begin early after onset of HIV infection

and extend throughout life. Infectiousness increases with increasing immune
deficiency; clinical symptoms and other STDs. Recent studies indicate that it
may be high during initial period after HIV infection. However patients on
Anti-Retroviral Therapy are less likely to transmit HIV infection to others.
HOST FACTOR

• Age incidence : Most cases occur in sexually active persons aged 20-49 yrs.
This group represents the productive members of the society, and those
responsible for child bearing and child rearing.
• Sex : AIDS is still most common among homosexual and bisexual men.
However, in more developed countries the disease is becoming more frequent
among heterosexuals, especially young people. In the UK, new cases of HIV
are now more prevalent among heterosexuals.
HOST FACTOR (CONT.)

• Immunity: genetic variations of two types of cytokines called interleukin-4 and interleukin-10 led
to an increased rate of disease progression. Also, specific types of HLA protein play a role in rate
of disease progression in an individual. The presence of other STIs, especially if ulcerative,
increases susceptibility, as may the fact of not being circumcised for males, a factor possibly
related to the general level of penile hygiene.
• High risk groups : Intravenous drug users and people with many sexual partners are particularly
at risk from HIV. Higher rate of HIV infection is found in CSWs and their clients, transfusion
recipients of blood and blood products, hemophiliacs. Certain persons are at high risk due to the
compulsions of their occupation, as truck drivers, military personnel, and migratory labour.
ENVIRONMENTAL FACTOR

• The researchers suggested that it was highly likely that the African patients
studied were infected with a different strain of HIV (called HIV-2) than the
one that normally infects homosexual men and injection-drug users in
Europe and North America (called HIV-1). If HIV-2 does not cause HIV
progression quicker outside of Africa, this suggests that environmental
factors, such as lack of access to antiretroviral therapy (ART) and treatment
for opportunistic infections, lead to the faster progression rates in Africa.
MODE OF TRANSMISSION &
PORTAL OF ENTRY
 MODE OF TRANSMISSION

• Sexual Majority of HIV infections are acquire by unprotected sex. The transmission of the virus
depends on
1. Strength and virulence of strain
2. Concomitant STDs: which causes mucosal breaks and rise in local macrophage population, so
that HIV can gain entry easily and finds macrophages to infect
3. Age and gender of receiver: In high-income countries, the risk of female-to-male transmission
is 0.04% per act and male-to-female transmission is 0.08% (i.e. women are twice as vulnerable
from getting the infection from men than men from women). This is because semen contains a
much higher concentration of virus than vaginal fluid, and women are exposed to the virus over
a much greater surface area (the whole of their vagina, cervix and endometrium) than men (who
contact vaginal fluid only at their glans). For various reasons, these rates are 4–10 times higher
in low-income countries. Adolescent girls and postmenopausal are more susceptible than those
in reproductive age.
MODE OF TRANSMISSION (CONT.)

4. Type of sex: Anal sex makes more mucosal breaks than vaginal or oral sex;
however, if the women is menstruating, vaginal sex can also get very risky.
5. Stage of disease: The HIV infected people are most infectious in Window
period and after they have developed AIDS.
MODE OF TRANSMISSION (CONT.)

• Transplacental: HIV may pass on during delivery of an HIV +ve mother. Probability of
infection is about one-fourth (if the mother does not breastfeed) to two-thirds (if she does
breastfeed). However, transmission rates can be lowered to 1% if the mother is given
chemotherapy. Mothers who already have AIDS will almost always transmit the virus.
Neonates born with HIV progress rapidly to AIDS.
• Contaminated needles: Accidental needle pricks (such as in health workers) with a needle
that has been contaminated with HIV +ve blood has only a 0.3% risk of HIV transmission.
Needle sharing between intravenous drug users (IDU), often multiple times a day, increases
the risk to 0.67%. Often such IDUs are also homosexuals.
MODE OF TRANSMISSION (CONT.)

• Blood transfusion: Blood is the most effective vehicle for HIV transmission
(95% efficacy), and in this regard, whole blood, cells, and coagulation factors
are all infective but NOT albumin, immunoglobulins or vaccines that are
prepared from blood

Portal of entry is through the parenteral route.

PATHOLOGY &
PATHOGENESIS
PATHOLOGY & PATHOGENESIS

• Incubation period: The 2–4 weeks immediately following infection are silent both clinically and
serologically.
• Acute HIV infection/ seroconversion illness: As the viral load rises, so as to be detectable in blood
the patient becomes infective, but has not yet begun to produce antibodies, which will appear only
after 2–12 weeks after infection. The period before antibody production is the window period, when
the person is particularly infective but will test negative for HIV antibodies, which are the standard
tests for HIV infection. Such patients can be diagnosed only by HIV RNA / p24 antigen testing in
blood. The appearance of antibodies (seroconversion) produces one or more of fever, arthralgia,
myalgia, lymphadenopathy, sore throat, mucosal ulcers, headache and photophobia, meningitis,
encephalitis, peripheral neuropathy or myelopathy in 50–70% of patients. The illness lasts between
6–9 weeks of infection and resolves completely as antibody titers rise in blood. Viral RNA and p24
antigen, and occasionally antibodies are detectable in blood this stage.
PATHOLOGY & PATHOGENESIS (CONT.)

• Asymptomatic carrier state: On an average, the virus replicates for ~10 years
while the person is asymptomatic. The viral load increases, and the CD4 counts
~50/ μl/year. Symptomatic disease appears only when CD4 count < 200.
• AIDS related complex/lesser AIDS: This precursor to AIDS surfaces with
diarrhea for > a month, fatigue, loss of weight, malaise, persistent generalized
lymphadenopathy (> 1 cm enlargement of lymph nodes at two or more
extrainguinal sites for more than 3 months in the absence of other causes) or
splenomegaly. Severe opportunistic infections are yet absent at this stage.
PATHOLOGY & PATHOGENESIS (CONT.)

• AIDS: Barring some rare nonprogressors, most HIV infection will progress to AIDS.
There are two kinds of manifestations of AIDS: those due to HIV itself (AIDS
dementia complex, weight loss, chronic diarrhea) and those due to
immunosuppression (opportunistic infections, cancers).
• Opportunistic infections: These are infections in the immunodeficient state:
Infections by obscure pathogens. Atypical presentations by known pathogens.
Typically the inflammatory response is absent (i.e. no neck rigidity may be seen in
meningitis). Best diagnosed only by visualization and culture (serology in unreliable).
CLINICAL FEATURES,
COMPLICATIONS &TREATMENT
CLINICAL FEATURES
CLINICAL FEATURES (CONT.)
COMPLICATIONS
TREATMENT

• There are several parts in treatment of HIV/AIDS:

1. Antiretroviral therapy
2. Treating opportunistic infections, and chemoprophylaxis (i.e. for
Pneumocystis jiroveci and mycobacteria)
3. Counseling the patient and raising his morale, knowing the disease can only
be slowed down, not cured.
PREVENTION, CONTROL &
IMMUNIZATION
PREVENTION & CONTROL

(a) Information, Education and Communication (IEC)

(b)Prevention of blood-borne HIV transmission
(c) Antiretroviral prophylaxis to prevent perinatal transmission and for post
exposure prophylaxis in cases of occupational exposure of Health Care
Worker (HCW).
(d)Administration of Antiretroviral Therapy
PREVENTION & CONTROL (CONT.)

(e) HIV and the Healthcare Worker Standard precautions are generally adequate
for the care of patients with HIV. They include hand washing before and after each
patient contact and the use of gloves. Other personal protective equipment, such as
gowns, eye shields and masks, are only necessary when exposure to blood or other
body fluids is anticipated.
(f) Prevention of Parent To Child Transmission (PPTCT) Good prenatal care,
adequate antiretroviral therapy to the mother and child, cesarean section, and
exclusive or no breastfeeding are all associated with decreased transmission of HIV.
IMMUNIZATION

• There are several approaches to vaccination for prevention of HIV-1 infection

a) Subunit vaccines : These vaccines use HIV-1 surface glycoproteins as immunogens.
b) Recombinant vector vaccines : The viral vectors are genetically engineered to carry HIV-
1 genes.
c) DNA vaccines : These vaccines consist of segments of genome or plasmid.
• A vaccine preparation may be used either alone or in combination with another HIV
vaccine. However no candidate vaccine has been proved effective till date due to extensive
genetic diversity of HIV strains.
RFFERENCES

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• http://www.who.int/gho/hiv/en/
• http://palestine.unfpa.org/sexual-reproductive-health#sthash.Lp09fkev.dpuf
• Salama, R. ACQUIRED IMMUNODEFICIENCY SYNDROME
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www.health24.com/Medical/HIV-AIDS/About-HIV-AIDS/Factors-affecting-HIV-progression-20130312
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• Community medicine; a student’s manual