HIV: Past and Future

1st March 2013
Phlebotomy
Association National
Conference
HIV Past and Future
Dr Dominic Rowley
MICGP MRCPI
Genitourinary SpR
• 77 y/o man
• Widower x 10 yrs,
• 4 adult kids, ex-smoker x many years
• Weight loss, diahorrea, anaemia,
•
MCH, MCV
• O/E Splenomegaly, mildly
axillary
nodes, mild anaemia, weight loss
• CXR: Clear
• CT TAP: Moderate splenomegaly
• Colonoscopy: Post Infective Colitis,
Biopsies: inflammatory
•
•
•
•
•
Coeliac screen –ve
Lymphoma workup –ve
Multiple myeloma screen –ve
Family Hx –ve
Foreign Travel: retired Long distance truck
driver European routes
• Sexual hx: denies any CSW, unprotected
sex
HIV Infection
• 1982 AIDS clinically seen in US
– PCP in immunocompetent MSMs and IVDU
•
•
•
•
Soon clusters of Kaposis Gay men
CDC; 4H disease
Media: GRID-Gay Related ImmuneDeficiency
1980 Gallo : a retrovirus – Human T-cell
Lymphotrophic Virus (HTLV 111)
• Montagnier : a retrovirus –called LAVLypmhadenoptahy assoc Virus
• 1986- both viruses found to be the same-HIV
1985
▪ As AIDS hysteria builds, Ryan White is barred from
school in Indiana.
▪ Rock Hudson dies of AIDS.
Lauren and Patrick Burk, and
their son Dwight, show the
impact of HIV/AIDS on the
heterosexual community.
“connection to blood and the idea of
passion -- not only anger, but love, like a
valentine."
1991-1992
▪ The red ribbon is introduced as a symbol of
AIDS solidarity.
▪ Magic Johnson announces he is HIV positive.
▪ Freddy Mercury dies of AIDS.
▪ AIDS becomes the leading cause of death in
U.S. men aged 25-44.
Roberto Duran hugs former boxing champ Esteban De Jesus, dying of AIDS
1993
▪ ACT UP and Benetton put a giant condom on the Place de Concorde in Paris.
▪ The play Angels in America wins the Pulitzer Prize.
▪ The CDC launches condom ads on TV.
www.hpsc.ie
HIV by year and risk factor
www.hpsc.ie
HIV Infection in Ireland
331 new HIV diagnoses in 2010
16.2% decrease compared to 2009
Heterosexual 37.2%
MSM had greatest rise accounts 40%
IVDUs account for only 6.6% infections
Pathogenesis
• Infects CD4+ lymphocytes and
monocytes/macrophages
• Produces 10
billion viruses per day
• Latent reservoir in CD4+ memory lymphocytes
Life Cycle of HIV
Binding, fusion
and entry
BINDING
Viral protease
PROTEASE
viral proteins
TRANSLATION
UNCOATING
genomic
RNA
double stranded
DNA
viral
mRNA
cell
membrane
ASSEMBLY
genomic
RNA
INTEGRATION
REVERSE
TRANSCRIPTION
Reverse
transcriptase
TRANSCRIPTION
cell nucleus
Viral integrase
proviral
RNA
Viral regulatory
proteins
When to start treatment ?
CD4 or T cell count <300-350
Viral load >30-40,000
Time
Treatment
CDC: By 2015 – over 50% of HIV positive individuals will be
over 50 years of age
4-6 weeks post infection
When will the undiagnosed HIV + pt present and to
whom?
Neurocognitive
dysfunction
Renal
dysfunction
Neurological
impairment present in
≥50% HIV+ patients3
30% of HIV+ patients
have abnormal kidney
function1
Cardiovascular
disease
Reduced bone
mineral density
75% increase in risk
of acute MI4
Increased prevalence
of osteoporosis or
osteopenia in spine,
hip or forearm:
63% of HIV+ patients2
1.
2.
3.
4.
5.
Gupta SK et al. Clin Infect Dis 2005;40:1559–85.
Brown TT et al. J Clin Endocrinol Metab 2004;89(3):1200–06.
Clifford DB. Top HIV Med 2008;16(2):94–98.
Triant VA et al. J Clin Endocrinol Metab 2007;92:2506–12.
Patel P et al. Ann Intern Med 2008;148:728–36.
Cancer
Increased risk of nonAIDS-defining cancers
e.g. anal, vaginal, liver,
lung, melanoma,
leukemia, colorectal
and renal5
Frailty
Increased frailty phenotype if HIV infected
3-14x; Associated with CD4 count
HIV in Ireland 2010
HIV undiagnosed
population
N= approx 1600
Or 135 new cases per
month for one year
HIV + not engaged in care
HIV + engaged in care
N=3254
80% on ARVs
Majority undetectable virus
Testing
• CDC USA 2006
– Separate consent not required
– Screening should take place in all health care
settings opt out
– Separate counselling not required
– People @ high risk should have annual
screening
HIV diagnosed prevalence: crude rates
Mayo
1.5 /1000
Dublin
0.0015
CSO
2011 Census Data
Patients Accessing Care for HIV in Ireland
Tuite et al.
p24
4th Generation tests
Combined Ag/Ab tests
Accurate at 12 days theoretically
Guidelines: recommend 12 weeks
• www.hpsc.ie
• Bloodborne Infections
HIV positive viral
load Detectable
Receptive anal sex
Insertive anal sex
Receptive vaginal sex
Insertive vaginal sex
Fellatio with ejaculation
Fellatio without ejaculation
Splash of semen into eye
Cunnilingus
Sharing of injecting equipment
Human bite
Recommend
Recommend
Recommend
Recommend
Consider
Not recommended
Consider
Not recommended
Recommend
Not recommended
HIV positive viral
load undectable
Recommend
Not recommended
Not recommended
Not recommended
Not recommended
Not recommended
Not recommended
Not recommended
Not recommended
Not recommended
Needle-stick from discarded
needle in the community
Risk of acquiring HIV=Risk of the contact having HIV x risk of the exposure
Unknown but HIV
prevalent group
Unknown/low
prevalence group
Recommend
Not
recommended
Consider
Not
recommended
Consider
Not
recommended
Consider
Not
recommended
Not recommended
Not
recommended
Not recommended
Not
recommended
Not recommended
Not
recommended
Not recommended
Not
recommended
Consider
Not
recommended
Not recommended
Not
recommended
Not recommended
Not
recommended
New BASSH Draft PEP Guidelines 2011
vaccines
• HIV
Testing –Consent/counselling –no need
New test accurate @ 4 weeks
• PEP
only recommended for needlestick from
KNOWN HIV+ source
www.Guideclinic.ie
THANK YOU