HIV/AIDS%20

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HIV/AIDS CLINICAL MANAGEMENT
Dr.K.BUJJI BABU,
MD.,STD, HIV/AIDS Skin
Dr.Bujji Babu HIV Clinic
Suryaraopet, Vijayawada
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GOALS

• Opportunistic infections
• Antiretroviral treatment
• Mother-to-Child Transmission
• Psychosocial issues
• Ethics

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HIV TRANSMISSION

• Exchange of body fluids
• Exchange of infected blood transfusion or by
  needle piercing
• Mother-to-child transmission
• 80-90 sexual contact

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WHO Classification

• Major signs
• - Weight loss gt10 of body weight
• - Fever more than one month int cont
• - Chronic diarrhoea more than one
• month intermittent and continues

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WHO Classification

• Minor signs
• - Persistent cough more than one month
• - Gen.itchydermatitis
• - Recurrent, multi-dermatomal herpes zoster
• - oral candidiasis
• - Chronic progressive and disseminated
• herpes simplex
• - Generalized lymphadenopathy

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CDC REVISED CLASSIFICATION

• CD4 T-cell A B C
• gt500/ul A1 B1
  C1
• 200-499/ul A2 B2 C2
• lt200/ul A3 B3 C3
• A- Asymptomatic or PGL
• B- Symptomatic
• C AIDS indicator

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CLASSIFICATION (CD4)

• CD4 cell count/ul Stage of HIV disease
• gt500 Early
• 500 200 Intermediate
• 200 50 Late or severe
• lt50 Far Advanced

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FIVE GOALS IN HIV CARE

• Prevention of further transmission
• Preservation of immune function
• Prophylaxis against OI
• Rx of OI through effective early diagnosis
• Counseling and other psychosocial supports

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COURSE OF HIV INFECTION

• Acute seroconversion syndrome in 1/3rd
• Phase of clinical latency
• CD4 lt200/ul, OI begins to set
• Progress to AIDS about 8-10 yrs

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OPPORTUNISTIC INFECTIONS

• Oral candidiasis
• - Oral discomfort
• - Burning sensation when eating
• - Altered sense of taste
• - KOH
• Oesophageal candidiasis
• - Odynophagia or dysphagia
• - Anterior chest pain, exacerbated by
  swallowing

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OPPORTUNISTIC INFECTIONS - DIARRHOEA

• Parasitic Criptosporidium, Isosporabelli
• Microsporidia, Giardia, EH
• Bacteria Solmonella, Campylobacter,
• C.difficile, M.tuberculosis

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DIARRHOEA

• Fungal Candidiasis, Histoplasmosis
• Viral - CMV, HSV, adenovirus,
• enterovirus, HIV
• M.C - Cryptosporidium, Isospora belli
• Microsporidium

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EMPIRIC ANTIBIOTIC RX

• TMP/SMX
• Ciprofloxacin
• Metronidazole
• Paramomycin

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COUGH FEVER

• Acute WBC abundant bacteria
• Sub acute Few WBC PCP
• Chronic AFB - TB
• Malaria, Typhoid, Viral fever
• Crypto
• Toxo

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CNS MANIFESTATIONS

• Cryptococcal meningitis
• Toxoplasmosis
• Tuberculous meningitis
• Progressive multi focal leukoencephalopathy
• Neurosyphilis
• Lymphoma

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CT scan post contrast multiple granulomas
(arrows) surrounded by minimal vasogenic edema.
Presence of multiple lesions with a target sign
and positive toxoplasma titre suggest
toxoplasmosis
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PULMONARY MANIFESTATIONS

• Pansinusitis
• Pulmonary or extra pulmonary tuberculosis
• PCP
• CMV

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CUTANEOUS MANIFESTATIONS

• Infectious dermatoses
• Viral infections
• Acute HIV,
• HSV,
• VZV
• EBV
• HPV

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BACTERIAL INFECTIONS

• Staphylococcal
• Mycobacterial
• Bacillary angiomatosis
• T.Pallidum infection
• Others Pseudo, salmo, nocardia

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FUNGAL INFECTIONS

• Superficial dermatophytosis
• Candidiasis
• Superficial mycoses
• Deep infections systemic mycoses
• Crypto, histo, coccidio, sporotrichosis,
  penicilliosis, blastomycosis, aspergillous

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PARASITIC INFECTIONS

• Arthropod infestations
• Scabies, demodicidosis
• Protozoal infestations
• Ex-pulmonary pneumocystosis,
• leishmaniasis, cutaneuous toxo,
• acanthamoebiasis

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NON-INFECTIOUS DERMATOSES

• Seborrheic dermatitis, psoriasis, Reiters,
  ichthyosiform dermatoses
• Papular and follicular eruption of HIV
• Pigmentary idsorders
• Adverse cutaneous drug reactions
• Neoplasms Kaposis, lymphoma, melanoma

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NAIL HAIR CHANGES

• Onychomycosis
• Yellowish discoloration of nail
• Melanotic bands black pigmentation of nail due
  to AZT
• Pre-mature graying of hair (Canities)
• Diffuse hair loss, male pattern alopecia,
  alopecia areata, hypertrichosis of the eye lashes

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STIs HIV

• Severe/extensive
• Atypical/chronic
• No response/minimal response to standard Rx
• Precocious syphils
• TPHA FTA ABS Positive

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STIs

• Syphilis, herpes, chancroid, granuloma inguinale,
  LGV, gonorrhea, trichomoniasis, bacterial
  vaginosis, vulvovaginal candidiasis, PID,
  ano-genital warts

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MANAGEMENT

• WHO(1997) CDC (1998)
• Higher dose of antimicrobials
• Prolonged duration of therapy

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OCCULAR MANIFESTIATIONS IN HIV

• Conjunctivitis
• Karatitis
• CMV retinopathy
• TB retinopathy
• Sudden retinal detachments

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ENT MANIFESTATIONS IN HIV

• Oropharyngeal candidiasis
• Middle ear disorders
• Pan sinusitis

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RENAL MANIFESTATIONS IN HIV
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GIT MANIFESTATIONS IN HIV

• Acute gastric duodenal ulcers
• Acute, sub acute, chronic cholecystitis
• Hepatitis HBV, HCV, HIV, CMV
• Pancreatitis
• Small bowel disorders
• Large bowel disorders
• Rectum, anal canal perianal disorders

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HAEMATOLOGICL DISORDERS IN HIV

• ANAEMIA

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CVS IN HIV

• Atherosclerosis due to CMV
• Cardiomyopathy due to CMV
• Cardiomyopathy due to anaemia
• CCF

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WOMEN HIV

• OI in women as same in men
• Recurrent vulvovaginal candidiasis
• Genital herpes, HPV
• Bacterial vaginosis PID
• Cervical dysplasia and neoplasia

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PAEDIATRIC HIV

• Diagnosis based on antibody tests gt18 M
• Immediate diagnosis antigen test
• DNA PCR, p24 antigen

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ANTI-RETROVIRAL THERAPY

• Clinical goal
• Virological goal
• Immunological goal
• Therapeutic goal
• Epidemiological goal

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INDICATIONS FOR ART

• Acute infection
• Symptomatic
• Asymptomatic
• - CD4 lt200 to 500
• - HIV RNA gt20,000 copies
• - RT-PCR gt10,000 copies bDNA

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ART

• NRTI AZT, ddI, ddC, d4T, 3TC
• NNRTI Nevi, delavir, efavir
• PI - Saq, ritonavir, ind, nelf, ampri
• Nucleotides adefovir, dipivoxil
• Miscellaneous Hydroxurea

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COMBINATION OF ART

• Mono therapy
• Duel therapy
• Highly active antiretroviral therapy
• Salvage therapy (rescue therapy)
• Recycling therapy
• Mega-HAART
• Subtraction regimen (step down therapy)

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ART IN TB

• No ART with Rifampicin
• Dual nucleoside therapy during rifampicin
• Triple therapy with Rifabutin
• Triple therapy with PI only with Ethambutol INH
  regimen

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PREVENTION OF MOTHER-TO-CHILD TRANSMISSION

• ART before, during, after delivery
• Infant AZT syrup 2mg/kg/QID for first six
  weeks, 8 to 12 hours after birth
• LSCS
• Postpartum care
• Breast feeding with ART

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PSYCHOSOCIAL MANAGEMENT

• Counseling
• - Relationship building
• - Assessment
• - Goal setting
• - Intervention
• - Termination follow up

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ETHICS

• Obligation of a physician to treat patients
• - World medical association (the
• professional responsibility of physicians
• in treating AIDS patients) should not
• refuse to treat a patient, a physician who
• is not able to provide care and service
• should refer to equipped hospitals.

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ETHICS

• Confidentiality
• - If individual feels that their status will
• be disclosed and in turn lead to
• discrimination, they may opt to get
• tested or treated, and that hinders
• offers to contain the epidemic

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Dr.Bujjibabu HIV Clinic
THANK YOU