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Clinical Care of HIV, AIDS and Opportunistic Infections
Unit 1: Natural History of HIV Disease and Overview of Opportunistic Infections
Unit 1: Overview Slide 2Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Learning Objectives
Participants will be able to:• Describe the natural history of HIV and AIDS
in adolescents and adults• Use the 2006 WHO clinical staging of HIV• Explain the meaning of ‘opportunistic’
infection or disease• Explain how CD4 lymphocyte count results
are used in developing a differential diagnosis
Unit 1: Overview Slide 3Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Definitions
• HIV• Human Immunodeficiency Virus
• Two types: HIV-1, HIV-2. • HIV-1 is the cause of the world-wide pandemic• Multiple HIV-1 subtypes or clades• Clades C and A are most common in southern Africa
• Clinical meaning - Can refer to persons with asymptomatic infection or symptomatic disease.
• HIV/AIDS• Used by MOHSS to describe the epidemic as a whole;
WHO is moving away from this term
Unit 1: Overview Slide 4Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Definitions (2)
• AIDS• Acquired Immunodeficiency Syndrome• Although used by the public to encompass the
whole epidemic, in the clinical sense it refers only to the most severe manifestation of infection with HIV
• Defined by the presence of life-threatening AIDS-defining conditions due to HIV-induced severe immunosuppression
• Opportunistic infections
• Some malignancies
Unit 1: Overview Slide 5Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Definitions (3)
• 2006 WHO definitions • Advanced HIV infection (most relevant for
patient management)• WHO Clinical Stage 3 or 4
– OR
• CD4 count < 350 cells/mm3
• AIDS• WHO Clinical Stage 4
» OR
• CD4 count < 200 cells/mm3
Unit 1: Overview Slide 6Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Question 1
• How long do people live after they acquire HIV infection, without HAART?
• How long does it take for a person with HIV to develop AIDS?
Unit 1: Overview Slide 7Training on Clinical Care of HIV, AIDS and Opportunistic Infections
CD4 Count, Viral Load and Clinical Course of Untreated HIV Infection in Adults
Pla
sma
HIV
RN
A
Viral Load
CD4 Cells
4-8 Weeks 5-10 Years to AIDS
CD
4 Cell
Co
un
t
1,000
500
Intermediate Stage AIDS
Primary Infection
Sero-conversion
Survival with AIDS 1 year
200
1
10
100
1,000
10,000
100,000
1,000,000
10,000,000
Unit 1: Overview Slide 8Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Natural History High Viral Load: Rapid Progressor
Normal
AIDS
Infection 2-3 years
CD4 cells> 500
CD4 cells< 200
High Viral Load
Unit 1: Overview Slide 9Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Natural History Low Viral Load: Long-Term Non-Progressor
Normal
Infection 10 years
CD4 cells> 500
Low Viral Load
Unit 1: Overview Slide 10Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Question 2
• What is the meaning of ‘opportunistic’ infection or disease?
Unit 1: Overview Slide 11Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Opportunistic Disease or Infection
Strict meaning:• An infection or disease that occurs only in
persons with weakened immune systems
Common meaning:• Any one of a number of infections or diseases
that occur often in persons with HIV or AIDS
Unit 1: Overview Slide 12Training on Clinical Care of HIV, AIDS and Opportunistic InfectionsWHO, 2006. http://www.who.int
Unit 1: Overview Slide 13Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Natural History:WHO Immunological Classification of HIV Infection
CD4 cellsCD4 cells>> 500 500
CD4 cellsCD4 cells499-350499-350
CD4 cellsCD4 cells349-200349-200
No significant No significant immunosuppressionimmunosuppression
MildMildimmunosuppressionimmunosuppression
Advanced immuno-Advanced immuno-suppressionsuppression
CD4 cellsCD4 cells< 200< 200
Severe immuno-Severe immuno-suppressionsuppression
Unit 1: Overview Slide 14Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Question 3
• How can you use CD4 lymphocyte count results in developing a differential diagnosis?
Unit 1: Overview Slide 15Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Relation Between CD4 Count and Types of Pathogens
CD4 cellsCD4 cells> 500> 500
CD4 cellsCD4 cells500-200500-200
CD4 cellsCD4 cells< 200< 200
Usual pathogensUsual pathogens
Usual pathogens;Usual pathogens;disease more frequent or disease more frequent or severesevere
Opportunistic Opportunistic pathogenspathogens
CD4 cellsCD4 cells< 50< 50
‘‘Severe’Severe’opportunistic opportunistic pathogenspathogens
Unit 1: Overview Slide 16Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Examples of Pulmonary Pathogens
CD4 cell count Pathogen Examples
> 500 UsualBacterial pneumonia
TB
500-200
Usual
More frequent
More severe
Bacterial pneumonia
TB
200-50 OpportunisticPneumocystis
TB
< 50 Opportunistic
MOTT or TB
CMV
Kaposi’s Sarcoma
Unit 1: Overview Slide 17Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Distribution of HIV Infected Persons and Levels of Immunosuppression
Stage 1
Stage 2
Stage 3
Stage 4 AIDS
Advancedimmunosuppression
No significantimmunosuppression
Mildimmunosuppression
Unit 1: Overview Slide 18Training on Clinical Care of HIV, AIDS and Opportunistic Infections
Key Points
• Persons with HIV may have normal immune function, or varying degrees of immunodeficiency
• Knowledge of the degree of immunodeficiency in an HIV+ person helps determine which infections or diseases are most likely
• The CD4 lymphocyte count, if available, helps determine the degree of immunodeficiency
• Staging of HIV disease is based on clinical factors, not CD4 counts