From Rotaract Club Of Mumbai Ghatkopar - RCMG

More about HIV/AIDS

"Leadership" has been chosen by the World AIDS Campaign as the theme for World AIDS Day 2007 and 2008. This theme will continue to be promoted with the slogan "Stop AIDS. Keep the Promise."—the World AIDS Campaign (WAC) emphasis from 2005-2010

• AIDS - Acquired Immunodeficiency syndrome
• HIV - Human Immunodeficiency Virus
• PCP- Pnemuocystis cariini pneumonia
• FSWs - Female sex workers
• MSM - Men who have sex with men
• NACO - National AIDS Control Organization
• First case of Immunodeficiency syndrome was recorded in 1981 by CDC, Atlanta among cases of PCP and Kaposi’s sarcoma in gay men, soon reported in minorities and IV drug users.
• First case of HIV infection in India was recorded in 1986, Madras Medical College.
• Cases were recorded in Mumbai from 1986 onwards – subtype C most common

Natural History of HIV Disease

• Exposure
• Primary HIV infection
• Seroconversion (Acute Antiretroviral Syndrome)
• Clinical latency period
• Early symptomatic HIV infection
• AIDS

Can the Natural History be Altered ?

• Recent decrease in morbidity and mortality in US and other developed countries
• Correlation with development of PIs and the advent of Highly Active Antiretroviral Therapy (HAART)

Primary Care : The Initial Evaluation

-History and review of systems -Physical examination -Laboratory evaluation -Immunizations

• Direct History
  • Sex with Commercial Sex Workers
  • Engaging in Drug Use involving Needles
  • MSM and sex with MSM
  • Often History Unclear
• Detection by corollary syndromes
  • STDs
  • Recent History of Tuberculosis
• Early Manifestations

Diagnosing HIV Infection

• Voluntary counseling
• HIV testing with combination of:
  • Enzyme Linked Imuunoabsorbent Assay (ELISA)
  • Western Blot
• Role of rapid tests
  • HIV Tri-Dot
  • Immunocomb HIV 1 & 2 BiSpot
  • Capillus HIV 1/HIV 2

Initial Evaluation :

History and Review of Systems - 1

• Constitutional symptoms: fever, chills, sweats, weight loss
• History of STD’s
• HEENT: altered vision, dysphagia
• Mucocutaneous: skin, oral, vaginal, anal

History and Review of Systems - 2

• Pulmonary: cough, dyspnea
• Gastrointestinal: odynophagia, diarrhea, hepatitis
• Neurological: headache, problems with memory, change in behavior or personality
• Behavioral health: anxiety, depression, Alcohol, drugs

Physical Examination :

• Skin: seborrhea, psoriasis, onychomycosis, HSV, VZV, KS
• Generalized adenopathy
• HEENT: CMV, retinitis, thrush, OHL
• Gastrointestinal: organomegaly
• Genitourinary: vaginitis, PID, HPV, cervical dysplasia, and carcinoma
• Neurological: mental status, focal central/peripheral findings

Baseline Laboratory Evaluation :

• HIV antibody test
• CBC, differential count
• BUN/creatinine, LFTs
• Glucose, lipid profile
• RPR
• Hepatitis A, B and C serologies
• Toxoplasmosis serology
• PPD, CXR
• Pap smear (vaginal and anal)
• CD4 cell count
• HIV viral load

Measurement of CD4 Count :

• Surrogate marker for HIV disease progression
• Normal > 500/mm3
• Average decline of 50-100 cells per year untreated
• Variability from patient to patient and over time in given patient
• Variability in an individual
  • Laboratory
  • Time of day
  • Intercurrent illness
  • Used to determine when to start ART and OI prophylaxis
  • Used before changing therapy

Measurement of Viral Load :

• Measurement of viral RNA by PCR or b-DNA
• General correlation with CD4 count
• Significant change at least 3-fold
• Inter-current illness and immunizations may affect value
• Used to determine when to begin ART and to assess its effectiveness
• Use limited due to costs

Adult Immunizations :

• Pneumococcal vaccine
• Hepatitis B vaccine
• Hepatitis A vaccine
• Influenza vaccine
• Tuberculosis testing
• Usual immunizations carried out in India

Considerations Regarding Initial Therapy

• All recommended ART regimens include at least THREE drugs!!!
• First regimen should be the most durable
• Prevent development of resistance
  • Effective and easy to use regimes
  • Promote adherence
  • Minimize toxicity
• Failure usually related to non-adherence

Counseling Patients About Prevention of HIV Transmission

• Counseling is done infrequently
• Taking a sexual history
  • Vaginal, anal intercourse and oral sex
• Need to stress prevention practices
  • HIV-negative patients
  • New patients
  • Patients with HIV disease
• Referral for specialised counseling

Counseling Patients about drug abuse

• Abuse of even oral drugs and alcohol can lead to increase in HIV transmission
• With respect to parenteral drug use:
  • Don’t share needles
  • Use clean needles
  • Are these legal and available?
  • Clean equipment
• Refer for rehabilitation centre
• The hard part: Bringing up the issue

HIV Concentration

• Low
  • Tears
  • Saliva
  • Urine

• High
  • Blood & Bloody Fluids
  • Sperm & Seminal Fluid
  • Cervical Secretions

Spectrum of Risk

• Safe
  • Hugging
  • Dry Kissing
  • Oral Sex

• Unsafe
  • Intercourse: Insertive or Receptive, Vaginal or Rectal

Preventing Infection After Exposure

• Evidence that infection may be prevented
• Protocols for Post Exposure Prophylaxis (PEP)
• Critical to have policies in place for health care workers
  • Protection of health care workers
  • Protection of patient’s rights
• Consider policies for exposure in other settings

Preventing Parent to Child Transmission of HIV (PPTCT)

• Discuss and encourage HIV counseling and testing with women
  • HIV infection compatible with normal pregnancy
• Provide information on effectiveness of treatment as well as prevention of transmission
  • ART (PPTCT)
  • Breast milk

The Core Primary Care Team :

Outpatient Clinics, Offices

• Primary physician
• Counselor
• US: nurse practitioners in outpatient setting
• Consultants including psychiatrist
• Nutritionist
• Addictions treatment
• Public health nurse
• Community worker
• Laboratory resources

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Acknowledgements: Dr. Kunal Sanghavi (smileheals@gmail.com)