UNIT 3

HIV EPIDEMIOLOGY,
DIAGNOSIS AND DISEASE
PROGRESSION
 Unit Objectives

 Define HIV and AIDS

 Describe how HIV works in the body
 Explain HIV transmission and factors that increase
the risk
 Explain different types of HIV tests, understand
NACO Testing strategies
 Define “window period” and sero conversion
 Describe progression and staging of HIV
 Explain Nurses’ Role in clinical staging

2
nd Understanding the
Immune System
• White blood cells (WBCs) are the most
important part of the immune system
• Macrophages act as clearing cells
• Neutrophils attack bacteria
• Eosinophils mediate allergies
• B-lymphocytes make antibodies
• T-lymphocytes
– Responsible for coordinating the immune system’s
attack on viruses, fungi and some bacteria
3
 Understanding the
Immune System
Important components of the immune
system

Lymphocytes

T4-lymphocytes B lymphocytes

CD4 type* CD8 type Antibodies

HIV uses CD4 cells for replication 4

What are HIV and AIDS?

5
 What is HIV?
Envelope Glycoprotein
Transmembrane gp 120
• Human: Glycoprotein – gp 41
– Can live only in
humans

• Immunodeficiency:
– Damages the
immune
system of people it
infects Reverse
Transcriptase

• Virus:
– Retrovirus (RNA/RT)
Nucleoid Core protein
Viral genome RNA p 24

6
 What Is AIDS?

Acquired Transmitted from person to

(not born with) person

Immune It affects the body’s immune

(body’s defense system) system, the part of the body
which usually works to fight
off germs such as bacteria
and viruses

Deficiency
(not working properly) Malfunctioning of the body’s
immune system
Syndrome
(a group of signs and Someone with AIDS may
symptoms) experience a wide range of
different diseases and OIs
7
 How Does HIV Work?

3. Integration into host cell’s

nucleus

4. Reproduction of
HIV viral components

1. Attachment
to host CD4
cell
5. Assembly of
new HIV
viruses
2. Reverse
transcriptase
makes DNA 6. Release
from the
virus’s RNA

Source: All About Antiretrovirals, Africaid 2004 8

HIV Lifecycle Video

9
 How Does HIV
make a person Sick?

• Immune suppression leads to

opportunistic infections

• Direct infection of major organs:

– Brain: HIV Encephalopathy
– Gut: HIV Enteropathy
– Kidneys: HIV Nephropathy
– Heart: HIV Cardiomyopathy

10
How Does HIV Cause AIDS?

Viral replication (8-10 years)

CD4 cell death

Further impairment of immune system

Increased likelihood of
opportunistic infections (OIs)

AIDS
11
 Difference between
HIV and AIDS

• HIV is a virus and AIDS is a disease

• HIV develops into AIDS
• AIDS is deficiency in the body’s defense
mechanism or immune system
• AIDS is acquired, not hereditary

12
Understanding HIV:
Review Questions
 True or False?

• HIV is a Retrovirus • HIV reproduces inside

• HIV disease is curable the CD4 cell
• HIV can live outside the
• The immune system
body
protects the body from
infections • HIV and AIDS are the
• Lymphocytes are a same
type of red blood cell • AIDS is caused by the
• AIDS is the end result AIDS virus
of untreated HIV • A person with AIDS
infection has a high CD4 count

14
HIV Transmission
 How HIV is Transmitted

Unprotected sex Sharing Occupational Exposure and

with a HIV + person Needles reusing instruments

Infected Blood During Pregnancy Breast Feeding

and Childbirth
16
 Which Body Fluids Have Risk
for HIV Contaminated Exposure?
Considered “At Risk” Considered “Not At
• Blood Risk”
• Semen • Tears
• Vaginal secretions • Sweat
• Cerebrospinal fluid • Urine and Feces
• Synovial, Pleural, • Saliva
Pericardial, Peritoneal
fluids Unless they contain visible
• Amniotic fluid blood
• Breast Milk
• Other body fluids visibly
contaminated with blood
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 How HIV Is NOT Transmitted

• Kissing/hugging
• Contact with sweat, tears, urine or faeces
• Insects bites (e.g. mosquitoes and bed
bugs)
• Bathing/Swimming in the same pond/pool
• Sharing cooking utensils, cups, toilet seats,
bedding, telephones or towels
• Eating food prepared by an infected person

18
 Biological Factors Affecting
HIV Transmission
Host Recipient
• High viral load • Young age/Female
• Primary infection • Poor health
• Advanced disease • Presence of STIs
• Presence of blood, • Exposure to blood,
semen or genital semen or genital
secretions during secretions
contact • Trauma during sexual
activity

19
 Women & Sexual
Transmission of HIV
• Women are at higher risk of getting HIV
through sexual contact than men because
of:
- Large amount of mucosal surface area in
vagina
- Pooling of semen during intercourse
• Women are especially vulnerable, when
they:
– Are young: due to immature genital tract
– Have STIs
– Are undergoing or have passed menopause 20
 What socioeconomic factors
might facilitate transmission of
HIV?
 Socioeconomic Factors

• Social Mobility
• Gender
• Poverty
• Cultural Factors
• Stigma and Denial
• Drug Use and Alcohol Consumption
• People in Conflict

22
 Effect of Bridge Populations
on Magnitude of HIV

High-risk Populations
•Sex Workers General population
•Trafficked women •Women
•Men who have sex with men ( married and unmarried)
•Needle sharing drug users •Babies and Children
•Youth
•Men
Bridge populations
• Clients of sex workers
• Partners of IDUs
• Migrant / mobile populations
• Truck drivers
• Population in conflict

23
 How is HIV diagnosed?

• HIV Antibody Tests

-HIV Rapid test
- ELISA
- Western Blot Test (Confirmatory
Test)
• HIV Antigen Tests
- DNA PCR
- P24 Antigen

24
 Antigen and Antibody

Antigen: Any substance that antagonizes or

stimulates the immune system to produce
antibodies (i.e. proteins that fight antigens).
Antigens are often foreign substances such
as bacteria or viruses

Antibody: A substance that is produced by

the immune system in response to
specific antigens, thereby helping the body
fight infection and foreign substances

25
 Untreated HIV
Disease
106
1000 HIV RNA
105
800

104
600
103

400 HIV Antibodies

102

200 CD4 + T cells 10

CD4
Count Window period
Viral
load
6 months 10 years ? 2 years
Primary Asymptomatic Symptomatic AIDS26
 HIV Antibody based Tests
• Most commonly used tests for diagnosis (age
> 18 months)
• Economical
• Rapid
• Can be performed easily in most laboratories
They are:
– Rapid Test (e.g. TriDot; Immunocomb)
– ELISA Test
– Western Blot Test (Confirmatory Test)

27
 HIV Antigen Based Tests
• Detect HIV sooner than antibody test
• Usually used for
– Diagnosis: age < 18 months
– Monitoring HIV disease progression
– Monitoring response to ARV therapy
• Expensive
• Require expertise to perform and interpret

They are:
-P24 Antigen
– HIV PCR
28
 Interpretation of Antibody Test Results:
Special Cases

• HIV positive individuals recently infected

in the window period could get negative
test results
– Usually 2-6 weeks
– Can be 2-12 weeks
– Rarely up to 6 months after exposure
• HIV negative children <18 months born to
HIV positive women can get positive test
results
29
 Sentinel Surveillance
• Monitoring of rate of occurrence of specific
conditions to assess the stability or change
in health levels of a population

• It is also the study of disease rates in a

specific cohort, geographic area,
population subgroup, etc.

• To estimate trends in larger population.

30
 HIV Sentinel Surveillance

• An annual exercise of collecting a stipulated number

of samples from different target populations, from
specific sites, across the country for HIV testing
• Provides information to understand the spread and
trends of HIV epidemic in different geographical
regions as well as in different population sub ‐groups
• Sampling is done at selected sentinel sites annually
for a period of three months
• HIV Testing strategy adopted is anonymous
unlinked

31
 NACO Testing Strategies

• Strategy I - all samples tested with one

ELISA/Rapid (E/R)- Used for
Transfusion/Transplant safety

• Strategy II A - all samples tested with one E/R,

reactive samples tested again on different system
(different antigen and principle) - Used for
Surveillance purposes

32
 NACO Testing Strategies
• Strategy II B - all samples tested with one E/R,
reactive samples from the first test tested with
different antigen preparation, reactive samples from
the second test again tested with third system (of
different antigen and principle)-Used for diagnosis of
an individual with AIDS indicator disease symptoms

• Strategy III- Same as above. But the Equivocal test

results are tested with Confirmatory test (DNA PCR
or Western Blot)

33
 NACO Testing Strategies

Objective of Testing Testing Strategy

Transfusion/ Donation I
safety
Surveillance II A
Diagnosis of symptomatic II B
patients
Asymptomatic patients III

34
 NACO Testing Strategies (I)
(For Transfusion/transplantation safety) One test kit
required

35
 NACO Testing Strategies (II A)
For Surveillance-2 test kits required

36
 NACO Testing Strategies (II B)
Diagnosis of an Individual with AIDS indicator disease symptoms (3 Test Kits Required)

37
 NACO Testing Strategies (III)
Detect HIV infection in asymptomatic persons(3 Test Kits Required)

38
 HIV Disease Progression

• Primary HIV infection or Acute Retroviral

Syndrome (ARS)
• Window Period
• Asymptomatic Chronic Infection
• Symptomatic HIV Infection
• Advanced HIV Infection/AIDS

(OIs are the leading cause of morbidity and mortality in HIV

infected individuals. The most common OIs are
preventable and treatable)
39
HIV Disease Progression
and
Clinical Staging
Common OI's Correlating
with Time and CD4 Count

41
 Clinical Staging for HIV-infected
Adults and Adolescents

Stage I
• Asymptomatic

• Persistent generalized lymphadenopathy

42
 Clinical Staging for HIV-infected
Adults and Adolescents
Stage II
 Unexplained moderate weight loss (<10% of
presumed or measured body weight)

 Recurrent respiratory tract infections (sinusitis,

tonsillitis, otitis media, pharyngitis)

 Herpes zoster

 Recurrent oral ulceration

43
 Clinical Staging for HIV-infected
Adults and Adolescents
Stage II (contd..)
 Papular pruritic eruptions (PPE)

 Seborrhoeic dermatitis

 Fungal nail infections

 Angular cheilitis

44
 Clinical Staging for HIV-infected
Adults and Adolescents
Stage III
 Unexplained severe weight loss (>10% of
presumed or measured body weight)
 Unexplained chronic diarrhoea for longer
than one month
 Unexplained persistent fever (above 37.5 oC
intermittent or constant for longer than one
month)

45
 Clinical Staging for HIV-infected
Adults and Adolescents
Stage III (contd..)
 Persistent oral candidiasis

 Oral hairy leukoplakia

 Pulmonary tuberculosis

46
 Clinical Staging for HIV-infected
Adults and Adolescents
Stage IV
 HIV wasting syndrome
 Pneumocystis pneumonia (PCP)
 Recurrent severe bacterial pneumonia
 Chronic herpes simplex infection (orolabial, genital
or anorectal of more than one month’s duration or
visceral at any site)
 Oesophageal candidiasis (or candidiasis of trachea,
bronchi or lungs)
 Extrapulmonary tuberculosis
 Kaposi’s sarcoma
47
 Clinical Staging for HIV-infected
Adults and Adolescents
Stage IV (Contd…)
 Cytomegalovirus infection (retinitis or infection of
other organs)
 Central nervous system toxoplasmosis
 HIV encephalopathy
 Extrapulmonary cryptococcosis including meningitis
 Disseminated non-tuberculous mycobacteria
infection
 Progressive multifocal leukoencephalopathy
 Chronic cryptosporidiosis
 Chronic isosporiasis 48
 Clinical Staging for HIV-infected
Adults and Adolescents
Stage IV (Contd…)
 Disseminated mycosis (extrapulmonary
histoplasmosis, coccidiomycosis)
 Recurrent septicaemia (including non-typhoidal
salmonella)
 Lymphoma (cerebral or B cell non-Hodgkin)
 Invasive cervical carcinoma
 Atypical disseminated leishmaniasis
 Symptomatic HIV associated nephropathy or
Symptomatic HIV associated cardiomyopathy.
49
 Nurse’s Role in Clinical Staging

• Identify, counsel and/or refer patients who

may need HIV testing

• Educate patients about:

-Healthy life style practices
-What to expect (e.g. OIs)
-Adherence to treatment

• Counsel patients about:

-Risk reduction strategies
-Palliative care
50
 Exercise 1

Clinical Staging Case Scenarios

 Case Scenario 1

• Mr. A, a 35-year-old HIV infected truck

driver is admitted to the ward with a
history of persistent diarrhoea since
five months
• His stool exam reveals cryptosporidium

52
 Case Scenario 2

• Ms B, a 24-year-old student was raped

• Two weeks later, she went to the doctor
complaining of fever, malaise, fatigue,
and swollen lymph nodes. She was
diagnosed with influenza

• Two months later, she is now

asymptomatic and has come for an HIV
test – her result is positive

53
 Case Scenario 3

• Ms C, a young woman comes to the clinic

complaining of fever for 6 weeks
• From her previous record, you see that six
months ago she weighed 54 kg. She now
weighs 46 kg
• She has scars on her back that are due to
herpes zoster
• Her HIV test done now come out positive
• She also has been diagnosed as having
Cryptoccocal Meningitis
54
 Exercise 2
Role Play: Typical Patient Questions
 Typical Patient Questions

• What is the difference between HIV and

AIDS?
• Will my family members also get infected?
• How does HIV make me sick?
• How much time do I have to live now that I
have HIV infection?
• How could I have gotten HIV infection if I
had sex with no one else but my wife?

56
 Key Points

• HIV is a virus that damages the immune system

• AIDS represents the end-stage disease that
results from untreated HIV infection
• HIV is transmitted through
• Unprotected sexual contact
• Transfusion of infected blood/blood products
• Sharing needles
• Infected mother to child during pregnancy, child birth
and breast feeding
• Women are at greater risk of acquiring HIV
through sex
• Contd…
57
 Key Points (Contd..)

• The rate at which HIV disease progresses to

AIDS varies from person to person
• PLHIV can be classified under four different
stages based on their clinical signs
• Nurses need to know about staging to:
– Identify and refer patients for HIV testing
– Plan case management effectively
• It is important to counsel, individuals at risk,
for testing, keeping in mind the “window
period” Contd…58
 Key Points

• Nurses need to explain different types of HIV

tests and testing process to patients when
required.

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Thank You!