Clinical features, diagnosis and management of HIV AIDS.

1. THE TIME TO ACT IS NOW……..

4. Clinical Presentations of HIV AIDS
The clinical features of HIV infection have been
classified in four broad categories:
• Initial infection with the virus and
development of Antibodies.
• Asymptomatic carrier state.
• AIDS related complex.
• FULL BLOWN AIDS
The UN defines adolescents as persons aged 10−19 years but, in the
present document, the category of adults and adolescents comprises
people aged 15 years and over for surveillance purposes.

5. REVISED WHO CLINICAL STAGING OF HIV/AIDS
Stages where a presumptive diagnosis can’t be made only on the basis
of clinical signs or simple investigations. Confirmatory diagnosis can be
achieved by CD4 count or percentage

6. REVISED WHO CLINICAL STAGING OF
HIV/AIDS
Conditions where a presumptive diagnosis can be
made on the basis of clinical signs or simple
investigations.
In clinical stage 4, there are a few conditions that have to
be tested via prescribed tests to be classified as AIDS
(According to WHO)

7. SIGNIFICANCE OF CD4 CELLS IN IMMUNOLOGICAL
STAGING
• CD4 cells are a kind of lymphocytes that activate your
body's immune system in case of an invasion. They are
also called T cells or helper T cells. Normal: 500-1600.
• CD8 cells are suppressor T or killer T cells.

8. SIGNIFICANCE OF CD4 CELLS IN
IMMUNOLOGICAL STAGING
• CD4 percentage is said to be of more use since CD4
counts can widely fluctuate. The normal range of % is
40-45%. A CD count of less than 200 corresponds to a
% of less than 17%.
• Clinical staging can be used effectively without access to
CD4 or other laboratory testing. However, CD4 testing is
useful for determining the degree of immunocompromise

9. CD4 LEVELS IN RELATION TO THE SEVERITY
OF IMMUNOSUPPRESSION IN ADULTS AND
ADOLESCENTS.
•>500/mm3Not significant
immunosuppression
•350 − 499/mm3Mild
immunosuppression
•200 −349/mm3Advanced
immunosuppression
•<200/mm3Severe
immunosuppression

10. CD4 LEVELS IN RELATION TO THE SEVERITY
OF IMMUNOSUPPRESSION IN INFANTS AND
CHILDREN
IMMUNE STATUS AGE UPTO 12
MONTHS
AGE FROM 13-59
MONTHS
AGE FROM 5
YEARS AND
OVER
NOT
SIGNIFICANT
MORE THAN 35% MORE THAN 25% GREATER THAN
500/MM3
MILD 25-34% 20-24% 350-499/MM3
ADVANCED 20-24% 15-19% 200-349/MM3
SEVERE LESS THAN 20% LESS THAN 15% LESS THAN
200/MM3

11. CLINICAL AND IMMUNOLOGICAL CRITERIA
FOR INITIATING ART IN ADULTS
AND ADOLESCENTS
Clinical stage
4: ART Treat.
Clinical stage 3:
Consider treatment:
CD4, if available, can
guide the urgency with
which ART should be
started.
Clinical stage
1 or 2: Only if
CD4
<200/mm3.

12. CLINICAL AND IMMUNOLOGICAL CRITERIA
FOR INITIATING ART IN
INFANTS AND CHILDREN
Clinical
stages
ART4:
Treat.
Presumptive
stage 4: Treat.
Stage 3:
Consider
treatment for all ages.
Children aged under 2
years usually require
ART.
CD4 %, if available
should be used to
guide decisions on
ART.
1 and 2:
Usually only where CD4
available.
• Under 12 months: CD4 % < 20
• 13-59 months : CD4 % < 15
• 5 years or over CD4
<200/mm3

13. ADVANCED HIV/AIDS DISEASE DEFINITIONS FOR
SURVEILLANCE FOR
ADULTS AND ADOLESCENTS
Any clinical stage 3 or stage 4 disease
or,
where CD4 is available, any clinical stage and
CD4 <350/mm3

14. ADVANCED HIV/AIDS DISEASE DEFINITIONS FOR
SURVEILLANCE FOR
INFANTS AND CHILDREN
Clinical stage 3 or stage 4 disease at any age
or
where CD4 is available, any clinical stage with
CD4 % <25% in children aged under 12 months
CD4 % <20% in children aged 12 -59 months
CD4 <350/mm3 in children aged 5 years and above

15. Relation between CD4 levels and
development of Opportunistic infections.
500/MM3: BACTERIAL
INFECTIONS, TB, HERPES
SIMPLES AND ZOSTER,
VAGINAL CANDIDIASIS, HIARY
LEUKOPLAKIA, KAPOSIS
SARCOMA
200/MM3: PNEUMOCYSTOSIS,
TOXOPLASMOSIS,
CRYPTOCOCCOSIS,
COCCIDIODOMYCOSIS,
CRYPTOSPORIODOSIS.
50/MM3: DISSEMINATED MAC
INFECTION, HISTOPLASMOSIS,
CMV RETINITIS, CNS
LYMPHOMA.

17. LABORATORY TESTS
ELISA
HIV Viral
load tests
Detection
of Viral
nucleic
acid
p24
antigen:
Western
Blot.
CBC.
CD4
count.
CD4
percentage
B2 Micro
globulin.
Antibody detection, though specific is hardly
preferred because of the significantly long
window period.

18. CLINICAL DIAGNOSIS OF AIDS.
WHO case definition for AIDS surveillance
In adults and
adolescents
• Major signs(2 or more):Weight loss, Persistent fever, chronic diarrhea.
• Minor signs(1 or more):Persistent cough, Generalised pruritic dermatitis, H/O
Herpes zoster, Orpoharyngeal Candidiasis, Herpes simplex.
Children
• Major signs(2 or more):Weight loss, slow growth, chronic diarrhea and fever
for more than a month.
• Minor signs(2 or more):Generalized Lymphadenopathy, Recurrent common
infections, Persistent cough and generalised rash.
Infant
• HIV antibody positive ( ELISA or RAPID ) aged under 18 months and
symptomatic with 2 or more of the following: Oral thrush, severe pneumonia,
severe wasting and malnutrition, severe sepsis, recent HIV related maternal
death, advanced AIDS in mother, confirmed AIDS in mother.

19. Expanded WHO case definition for AIDS surveillance.
More than
10% of the
body weight
lost with fever
or cachexia or
both for a
month.
Cryptococcus
meningitis
Pulmonary or
extra
pulmonary TB
Kaposi's
sarcoma
Neurological
impairment
Candidiasis of
the Esophagus
Clinically
diagnosed life
threatening or
recurrent
episodes of
clinical
Pneumonia
An adult or an adolescent is said to have AIDS if one of the tests for HIV
antibody gives a positive result and one or more of the following are present:

21. Classification of drugs used for ART (Anti
retroviral therapy)
• Abacavir(ABC), Didanosine(DDL), Lamivudine(3TC), Stavudine(D4T),
Zidovudine(AZT), Emtricitabine(FTC)
NUCLEOSIDE REVERSE
TRANSCRIPTASE
INHIBITORS(NRTIs)
• Raltegavir(RAL)
INTEGRASE STRAND
TRANSFER
INHIBITORS(INSTIs)
• Atazanavir+ritonavir(ATV/r), Darunavir+ritonavir(DRV/r), Fos-
amprenavir+rotinavir(FPV/r), Indinavir+ritonavir(IDV/r),
ritonavir/lopinavir(LPV/r), saquinavir, indinavir(SQV/r).
PROTEASE
INHIBITORS(PIs)
• Tenofovir(TDF)
NUCLEOTIDE REVERSE
TRANSRIPTASE
INHIBITORS(N tRTIs)
• Efavirenz(EFV), Etravirine(ETV), Nevirapine(NVP).
NON NUCLEOSIDE
REVERSE
TRANSCRIPTASE
INHIBITORS(NNRTIs)

22. Outline of the mechanism of how these
drugs work

23. PREFERRED FIRST LINE ART IN
TREATMENT(2013).
 TDF + 3TC (or FTC) + EFV as a fixed-dose
combination.
 If TDF + 3TC (or FTC) + EFV is contraindicated or not
available:
• AZT + 3TC + EFV
• AZT + 3TC + NVP
• TDF + 3TC (or FTC) + NVP

24. First-line ART for pregnant and breastfeeding
women and ARV drugs for their infants
• Pregnant and breast feeding women = TDF + 3TC (or FTC)
+ EFV
• Infants of mothers who are receiving ART and are
breastfeeding = Daily NVP or twice daily AZT

25. First-line ART for children younger than three
years of age
• A LPV/r-based regimen = Less than 36 months of age. If
not feasible, NVP based regimen.
• Less than 3 years of age who have developed TB = ABC
+ 3TC + AZT

26. First-line ART for children three years and
older (including adolescents).
• EFV is the preferred NNRTI for first-line treatment and
NVP is the alternative
• For children infected with HIV three years to less than 10
years old (or adolescents less than 35 kg):
• ABC + 3TC
• AZT or TDF + 3TC (or FTC)

27. Second-line ART: what ARV regimen to
switch to ?
After failure on a
TDF + 3TC (or
FTC) -based first-
line regimen = AZT
+ 3TC.
Combinations of
ATV/r and LPV/r
are the preferred
boosted PI options.
After failure of a first-
line NNRTI = A
boosted PI + 2 NRTIs
are recommended;
LPV/r is the preferred
boosted PI

28. Second-line ART: what ARV regimen to
switch to ?
After failure of a
first-line regimen
of ABC or TDF +
3TC (or FTC) =
AZT + 3TC.
After failure of a
first-line regimen
containing AZT
or d4T + 3TC (or
FTC) = ABC or
TDF + 3TC (or
FTC)
After failure of a
first-line LPV/r-
based regimen,
children 3 years
or older = NNRTI
plus two NRTIs;
EFV is the
preferred NNRTI

29. Third-line ART
THIRD LINE ART
New drugs
with
minimal
risk of
cross-
resistance
Policies for
third line ART .
Patients with no
new ARV
options should
continue with a
tolerated
regimen.

30. MONITORING ART RESPONSE AND
DAIGNOSIS OF TREATMENT FAILURE.
Viral load monitoring
approach to diagnose
treatment failure.
If viral load not
available, CD4 count
and clinical monitoring
can be used.

31. WHAT IS POST EXPOSURE PROPHYLAXIS.
• Post-exposure prophylaxis (PEP) involves taking anti-HIV
medications as soon as possible (within 3 days) after you
may have been exposed to HIV to try to reduce the chance
of becoming HIV positive.
• PEP must begin within 72 hours of exposure.
• PEP is not 100% effective.
Go immediately.

32. DETERMINING EXPOSURE CODE

33. DETERMINING THE HIV STATUS CODE.

34. Post-exposure prophylaxis to prevent HIV
infection
• For adults: Tenofovir combined with either
Lamivudine (3TC) or Emtricitabine (FTC).
• For children: Zidovudine (AZT) and Lamivudine (3TC)
with ritonavir-boosted lopinavir (LPV/r) recommended
as the third drug choice.

35. Guidelines on post-exposure prophylaxis for HIV
and the use of Cotrimoxazole prophylaxis
Infants
Start at 4-6 weeks
and continue until
proven otherwise.
Regardless of CD4
count and
symptoms until 5
years of age
1 – 4 years
Start if in stage II,
III or IV or CD4
count is less than
25%.
Not given to
children who show
severe adverse
reactions.
Adults and
adolescents
CD count below
350 or stage III
and IV
CD count not
available; to the
ones with evident
symptoms.
Pregnant
women
Regardless of
count or symptoms
To be continued in
feeding as well

36. REHABILITATIVE MANAGEMENT OF HIV
AIDS.
Three primary
goals of
rehabilitation are:
To increase or
maintain
functional
capacity
To improve or
maintain a
person’s quality
of life, and
To decrease
hospitalizations
and increase
self care

37. REHABILITATIVE MANAGEMENT OF HIV
AIDS.
• Impairments.
• Activity
Limitations.
• Participation
Restrictions.
The model
lays out three
categories,
from micro
level (body
part,
individual) to
macro level
(community
or society):

39. INTERNATIONAL AIDS PREVENTION
INITIATIVE
Goals:
• Provide a creative means for
remembrance and healing
• Illustrate the enormity of the AIDS
epidemic
• Increase public awareness of
AIDS
• Assist with HIV prevention
education
• Raise funds for community-based
AIDS service organizations

40. INTERNATIONAL AIDS VACCINE
INITIATIVE
• Currently there is no vaccine to prevent HIV AIDS.
• Recent scientific discoveries and the RV144 trial.

41. NATIONAL RESPONSE TO THE
PROBLEM OF HIV AIDS
The first case of
AIDS was reported
in India in 1986.
Soon after the
government
introduced a high
power committee in
1986 itself.
First
acceleration(1992-
1999) { The launch
of NACP 1 }.
From 1996 to
2006:NACP Phase 2
with focus on
targeted
intervention.
During this phase,
State AIDS control
societies(SACS)

42. SACS Structure
Autonomous and Decentralized
Has on board representatives from key
governing bodies
For better financial and operational
efficiency, administrative and financial
powers are vested in the Executive
Committee and the Programme Director.

43. Function of SACS are:
Medical and public
health services
Communication and
social sector services
Administration,
planning, coordination,
monitoring, evaluation
etc…

44. NATIONAL AIDS PREVENTION AND CONTROL POLICY
2002
• It was launched with the aim to bring AIDS transmission
to zero level by 2007 by adapting the following
strategies:
• Prevention of further spread.
• By providing an enabling socio economic
environment.
• Improving services.
• NATIONAL HEALTH POLICY 2002 SET AN AIM FOR
AIDS CONTROL SO AS ACHIEVE ZERO LEVEL
GROWTH OF NEW HIV AIDS CASES BY 2007.

45. NATIONAL AIDS CONTROL PROGRAMME PHASE 3.
2007-2012
Goals:
• Prevention of new infections in high risk groups
and general population
• Providing care, support and treatment to more
number of people living with AIDS.
• Strengthening the infrastructure, resources and
man power resources.
• strengthening the nationwide strategic
information management system.

46. saturation of coverage to high
risk groups
scaling up intervention
amongst general population
Improved treatment access
more number of people on
ART
Establishing pediatric ART
financing of ART drugs
Integration of prevention with
care, support and treatment.
Focus on children.
capacity building of SACS,
NACO and DACS
TARGETS AND
STRATEGIES:

47. 6000 condom
depots have been
established
6000 village
information centers
have been
established
red ribbon clubs
have been
established
mid media
programs to be
established and
programmed.
mapping of high
risk groups and
migrants
development of
training modules
Progress under NACP3

48. XII FIVE YEAR PLAN
2012-17.
The government
approved a budget of
8632.77 crores for
NACP phase 4.
80% reduction in new
cases in high
prevalence rates and
60% in low
prevalence rates.
Comprehensive care,
support and treatment
for PLHA and
strengthening the
program initiatives.
intensifying and
consolidating quality
prevention services
and enhancing access,
quality and coverage
increasing access
and promoting
innovative
sustainable
mechanisms
expanding services
for high risk and low
risk groups and
strengthening
institutional capacities

49. NATIONAL AIDS CONTROL PROGRAMME IV
Strategies under NACP IV:
Target
intervention for
migrants
Target
intervention by
NACO and SACS
Non TI programs
by NGOs
Work place
intervention
Target
intervention for
truckers
Increased cover
of LDTs
Operationalize
national network
of truckers
Ensure
universal access
to services
Strengthen the
quality of
information
shared

50. Target intervention amongst female sex workers:
• Increased coverage in north India
• Improving quality of intervention
• active participation and sharing of responsibility
• building ownership, leadership and accountability of
SACS
• reaching out deeper
• addressing trafficking and violence
• convergence of prevention, care support and treatment
• development of district, state and community level
resources

51. Target
intervention
amongst
Hijras and
Transgender
By providing
a minimum
package of
condoms and
lubes
services for
HIV +ve ones
sexual health
services
providing a
enabling
environment
by targeted
media
campaigns

52. Target intervention towards MSM (Men who have sex
with men)
Towards zero new cases amongst MSM by
the end of 2017, and universal access to prevention,
care, support and treatment by:
• Reaching a diverse group of MSM
• By providing a comprehensive package of prevention,
care, support and treatment
• to create and sustain enabling environment
• to mobilize and strengthen their communities to
contribute to national responses

53. STD control programme was launched with the objectives
to:
• Reduce STD cases and thereby reduce HIV cases
• prevent short term as well as long term morbidity and
mortality due to AIDS and STDs
The strategies are as follows:
• develop adequate and effective program management
• promote IEC activities for the prevention and
transmission
• make adequate arrangements for the adequate and
comprehensive case management
• increasing access to health care
• creating facilities for diagnosis and treatment
• By adapting a syndromic approach

54. Laboratory services launches by NACO: National
external quality assessment scheme(NEQAS)
Objectives:
• monitoring lab performances and monitoring quality
levels
• establishing intra laboratory comparability
• promoting high standards
• encouraging use of standard quality instruments and
reagents
• influencing reliability
• identifying common error
• facilitate information exchange
• supporting accreditation
• Education

55. NEQAS set up 4
tiers of laboratories:
1) Apex in national
AIDS research
institute Pune
2) 13 national
reference labs
3) 118 state level
labs
4) district level labs

56. VOLUNTARY COUNSELLING AND TESTING.
Objectives of Voluntary counselling and testing (VCT)
• To provide the client with information on the HIV test,
its benefits and the risks involved.
• The aim is to have the informed consent of the client
before the test and to help the client gain a better
understanding of the test results.
• To provide the client with background information on
HIV/AIDS infection, modes of transmission,
preventive methods, treatment and care.

57. • To assess the risk of HIV infection in the client.
• To encourage and maintain a safe behaviour to avoid
future infection and/or to prevent the further spread of
HIV (e.g. through safe sex and changing drug
injecting practices).
• To help the client to handle possible emotional
reactions related to the HIV test results (e.g. grief,
anger, fear and denial).
• To discuss courses of action adapted to each client,
his family needs and circumstances.

58. The main functions of ICTCs are to:
• Early detection
• provision of basic information on AIDS
• link people with other services such as prevention, care
and treatment services
Types of ICTCs:
• FIXED FACITLITY: Stand alone and facility integrated
• MOBILE ICTCs.

59. To offer HIV test
to all pregnant
women.
To reduce PTCT
to less than 5%
PPTCT( PREVENTION
OF PARENT TO
CHILD
TRANSMISSION)
PROGRAMME

60. strengthening
the national
blood
transfusion
programme
ensuring
adequate
supply of
blood to all
centers
ensuring
safety
developing
facilities
strengthening
quality control
undertaking
research on
blood
transfusion
techniques
effective
management
and
monitoring of
blood
transfusion
techniques
SAFE BLOOD PROGRAMME.

61. Technical assistance to companies to manufacture condoms
strengthening the marketing structure
Strengthening the management ability of private organizations
collaborating with the existing programmes
strengthening program management
supporting and strengthening the ICMR and other research institutes for
undertaking research on condoms.
CONDOM PROGRAMME