Dr Yasir A.

Shamboul MD

HIV AND AIDS

Omdurman Islamic University
Collage Of Medicine And Health
Science
Assistant Professor Of Internal
Medicine
HISTORICAL
BACKGROUND
First Identifications:
 HIV identified in the early 1980’s.

Origins:
 Believed to have originated from non-human primates in
Central Africa.
Major Milestones:
 1981: First cases of AIDS reported.
 1983: HIV virus identified.
 1987: AZT, first antiretroviral drug approved.
GLOBAL EPIDEMIOLOGY
OF HIV/AIDS
Global Statistics:
 Number of people living with HIV: ~38 million
 New infections and deaths per year

Regional Distribution:
 Highest prevalence in Sub-Saharan Africa
 Trends in other regions
EPIDEMIOLOGY IN SUDAN
Prevalence:
 Approximately 0.2-0.3% of the population.

Risk Factors:
 Cultural practices, low condom use, stigma.

Government Initiatives:
 National HIV/AIDS control programs.
HIV MICROBIOLOGY AND
PATHOPHYSIOLOGY
Virus Structure:
 Retrovirus, RNA genome
 Key proteins: gp120, gp41

Life Cycle:
 Entry: HIV binds to CD4 receptor and co-receptors (CCR5 or CXCR4) on
host cells.
 Reverse Transcription: Viral RNA is reverse transcribed to DNA by
reverse transcriptase.
 Integration: Viral DNA integrates into the host genome via integrase.
 Replication: Host cell machinery produces viral RNA and proteins.
 Assembly and Budding: New virions are assembled and bud off from the
HIV MICROBIOLOGY AND
PATHOPHYSIOLOGY
Impact on Immune System:
 CD4+ T cell Depletion: Direct viral killing, immune-
mediated killing, and apoptosis.
 Immune Activation: Chronic immune activation leads to
immune exhaustion and further depletion of CD4+ T cells.
 Opportunistic Infections: Result from severe
immunosuppression.
CLINICAL
MANIFESTATIONS
Acute HIV Infection Fever
 This is the earliest stage of Chills Sore throat
HIV, typically occurring
within 2 to 4 weeks after Rash Fatigue
exposure to the virus. Some Night Swollen
people may experience a sweats lymph nodes
flu-like illness, known as
acute retroviral syndrome Muscle Mouth
(ARS) or primary HIV aches ulcers
infection. Symptoms can
include:
CLINICAL
MANIFESTATIONS
Chronic HIV Infection Persistent generalized
lymphadenopathy (swollen
(Clinical Latency Stage) lymph nodes)
 In this stage, the virus is still
Recurrent respiratory
active but reproduces at very low
infections
levels. People may not experience
any symptoms or only mild ones. Skin conditions, such as
This stage can last for several seborrheic dermatitis or
psoriasis
years (even decades) with proper
treatment. Without treatment, the Weight loss
virus will eventually progress to Night sweats
AIDS. Clinical features can include:
Diarrhea
CLINICAL
MANIFESTATIONS
AIDS
 AIDS is the most severe phase of HIV infection. It is
diagnosed when the CD4 cell count drops below 200
cells/mm³ or when certain opportunistic infections or
cancers occur.
CLINICAL
MANIFESTATIONS
AIDS
Opportunistic Pneumocystis jirovecii
pneumonia (PCP)
Infections
These are infections that Tuberculosis (TB)
occur more frequently and Candidiasis (thrush)
are more severe in
Cytomegalovirus (CMV)
individuals with weakened
immune systems. Common Herpes simplex virus
opportunistic infections (HSV) infections
include: Toxoplasmosis
CLINICAL
MANIFESTATIONS
AIDS
Cancers Other Clinical Features
 Certain cancers are more  Severe weight loss (wasting
syndrome)
common in people with
 Chronic diarrhea
AIDS, such as:
 Kaposi’s sarcoma
 Neurological disorders (such
as HIV-associated dementia)
 Lymphomas (including
 Skin rashes and sores
primary central nervous
system lymphoma)  Frequent fevers and night
 Invasive cervical cancer sweats
AIDS-DEFINING
ILLNESSES
Pneumocystis jirovecii Pneumonia (PCP):
 Symptoms: Cough, fever, dyspnea, exertional desaturation.
 CD4: <200 cells/mm³.
 Diagnosis: Sputum sample, bronchoalveolar lavage.
 Treatment: TMP-SMX (Trimethoprim-Sulfamethoxazole).
AIDS-DEFINING
ILLNESSES
Toxoplasmosis of the Brain:
 Symptoms: Headache, confusion, seizures.
 CD4: <100 cells/mm³.
 Diagnosis: Brain imaging (CT/MRI), serology.
 Treatment: Pyrimethamine, sulfadiazine, and leucovorin.
AIDS-DEFINING
ILLNESSES
Mycobacterium Avium Complex (MAC):
 Symptoms: Fever, night sweats, weight loss.
 CD4: <50 cells/mm³.
 Diagnosis: Blood cultures, lymph node biopsy.
 Treatment: Clarithromycin or azithromycin plus ethambutol.
AIDS-DEFINING
ILLNESSES
Esophageal Candidiasis:
 Symptoms: Odynophagia, dysphagia.
 CD4: <200 cells/mm³.
 Diagnosis: Endoscopy with biopsy.
 Treatment: Fluconazole.
AIDS-DEFINING
ILLNESSES
Kaposi's Sarcoma:
 Symptoms: Purple lesions on skin, mucous membranes.
 Any CD4 count.
 Diagnosis: Biopsy.
 Treatment: ART, chemotherapy.
AIDS-DEFINING
ILLNESSES
Cytomegalovirus (CMV) Retinitis:
 Symptoms: Visual disturbances, floaters.
 CD4: <50 cells/mm³.
 Diagnosis: Fundoscopy.
 Treatment: Ganciclovir, valganciclovir.
AIDS-DEFINING
ILLNESSES
Progressive Multifocal Leukoencephalopathy
(PML):
 Symptoms: Neurological deficits, cognitive decline.
 CD4: <100 cells/mm³.
 Diagnosis: Brain MRI, JC virus DNA in cerebrospinal fluid.
 Treatment: No specific antiviral therapy, ART to improve
immune function.
RISK FACTORS FOR
HIV/AIDS
Behavioral Risk Factors: Social and Economic
 Unprotected sex (vaginal, anal, Factors:
oral).  Stigma and discrimination.
 Multiple sexual partners.  Low socioeconomic status.
 Intravenous drug use (sharing  Limited access to healthcare.
needles).  Gender-based violence.
Biological Risk Factors: Other Factors:
 Presence of other sexually  Blood transfusions with
transmitted infections (STIs) (e.g., contaminated blood.
genital ulcers).
 Vertical transmission from mother
 Male circumcision status
to child during pregnancy,
(uncircumcised men have higher childbirth, or breastfeeding.
risk).
DIAGNOSTIC METHODS
Serological Tests:
 ELISA (Enzyme-Linked Immunosorbent Assay): Initial
screening test.
 Western Blot: Confirmatory test.
 Rapid Diagnostic Tests: Provide results in 20-30 minutes.

Molecular Tests:
 PCR (Polymerase Chain Reaction): Detects viral RNA,
useful in acute infection.
 Genotypic Resistance Testing: Identifies mutations
associated with drug resistance.
DIAGNOSTIC METHODS
New Methods:
 Fourth-Generation Tests: Detect both antibodies and p24
antigen, reducing the window period.
 Point-of-Care Tests: Portable and useful in resource-
limited settings.
PHARMACOLOGICAL
MANAGEMENT
Antiretroviral Therapy (ART):
Classes of drugs:
 NRTIs (Nucleoside Reverse Transcriptase Inhibitors): Zidovudine,
Lamivudine.
 NNRTIs (Non-Nucleoside Reverse Transcriptase
Inhibitors): Efavirenz, Nevirapine.
 PIs (Protease Inhibitors): Lopinavir, Ritonavir.
 INSTIs (Integrase Strand Transfer Inhibitors): Raltegravir,
Dolutegravir.
 Entry Inhibitors: Enfuvirtide, Maraviroc.
PHARMACOLOGICAL
MANAGEMENT
Mechanisms of Action:
 NRTIs: Block reverse transcription.
 NNRTIs: Inhibit reverse transcriptase enzyme.
 PIs: Prevent viral protein processing.
 INSTIs: Inhibit viral DNA integration.
 Entry Inhibitors: Block HIV entry into cells.
PHARMACOLOGICAL
MANAGEMENT
Importance of Early Detection and Treatment
 Antiretroviral Therapy (ART): ART helps to control the
virus, maintain immune function, and prevent progression
to AIDS. It is crucial for:
 Reducing Viral Load: Keeping the viral load at undetectable levels.
 Increasing CD4 Count: Helping the immune system recover and
function properly.
 Preventing Opportunistic Infections: Reducing the risk of life-
threatening infections.
 Improving Quality of Life: Allowing individuals to live healthier,
longer lives.
 Reducing Transmission: Lowering the risk of transmitting the virus
to others.
ART REGIMENS AND SIDE
EFFECTS
First-Line Regimens: Common Side Effects:
 Tenofovir/Emtricitabine +  NRTIs: Lactic acidosis,
Efavirenz. hepatomegaly.
 Dolutegravir +  NNRTIs: Rash,
Tenofovir/Emtricitabine. hepatotoxicity.
 PIs: Lipodystrophy,
Second-Line hyperlipidemia.
Regimens:  INSTIs: Insomnia,
 Protease inhibitor-based
headache.
regimens (e.g.,  Entry Inhibitors: Injection
Lopinavir/Ritonavir).
site reactions (Enfuvirtide).
NON-PHARMACOLOGICAL
MANAGEMENT
Lifestyle Modifications:
 Safe sex practices (e.g., condom use).
 Harm reduction for drug users (e.g., needle exchange programs).
Support Services:
 Counseling and mental health support.
 Nutritional support and supplementation.
 Social support services.
Preventive Measures:
 Regular screening for sexually transmitted infections (STIs).
 Vaccinations for preventable diseases (e.g., Hepatitis B, HPV).
 Education and awareness programs.
PEP (POST-EXPOSURE
PROPHYLAXIS)
Indications:
 Occupational exposure (e.g., needlestick injuries).
 Non-occupational exposure (e.g., sexual assault).
Regimen:
 Start within 72 hours of exposure.
 28-day course of ART: e.g., Tenofovir/Emtricitabine + Raltegravir.
Follow-Up:
 Baseline and follow-up HIV testing at 4-6 weeks, 3 months, and
6 months post-exposure.
 Monitoring for side effects.
PREP (PRE-EXPOSURE
PROPHYLAXIS)
Indications:
 High-risk individuals (e.g., serodiscordant couples, MSM, people who
inject drugs).
Regimen:
 Daily oral PrEP: Tenofovir/Emtricitabine.
Efficacy:
 Significantly reduces risk of HIV acquisition when taken consistently.
Monitoring:
 Regular HIV testing (every 3 months).
 Kidney function monitoring (every 6 months).
 Counseling on adherence and risk reduction.
HIV AND CO-INFECTIONS
HIV and Tuberculosis
HIV and Leishmaniasis:
(TB):
 Epidemiology: TB is a leading cause  Epidemiology: Co-infection is
of death among people with HIV. common in endemic areas.
 Interaction: HIV weakens the  Interaction: HIV increases the
immune system, increasing risk of visceral leishmaniasis, and
susceptibility to TB.
leishmaniasis can accelerate HIV
 Management: Concurrent treatment
progression.
with ART and anti-TB therapy. Drug
 Management: Combination
interactions must be managed (e.g.,
Rifampin and Protease Inhibitors). therapy for both infections.
Enhanced monitoring and
supportive care.
FOLLOW-UP AND
MONITORING
Regular Monitoring:
 CD4 Count: Every 3-6 months initially, then every 6-12 months once stable.
 Viral Load: Every 3-6 months.
 ART Adherence: Regular counseling and support to ensure adherence.

Management of Comorbidities:
 Screening and management of cardiovascular disease, liver and kidney function.
 Bone health monitoring (e.g., DEXA scans for osteoporosis).

Preventive Care:
 Vaccinations as per guidelines.
 Regular screenings for cancers (e.g., cervical, anal).
CONCLUSION AND
TAKEAWAYS
Summary:
 Early diagnosis and initiation of ART are crucial for improving outcomes.
 Comprehensive care involves both pharmacological and non-
pharmacological strategies.
 Co-infections like TB and leishmaniasis require integrated management.

Future Directions:
 Ongoing research into HIV vaccine development.
 Strategies for curing HIV, including gene therapy and immunotherapy.
 Continued efforts in education, stigma reduction, and global access to
care.
REFERENCES
Manson's Textbook of Tropical Medicine
Davidson's Principles and Practice of Medicine
CDC Guidelines
WHO Resources