HIV and Disease Related S01 IKT

HIV/ AIDS and Related Diseases

Dr. Musofa Rusli, Sp.PD Div. of Tropical – Infectious Disease, Dept. of Internal Medicine

Faculty of Medicine Universitas Airlangga

Master Class Lecture

Lecture Contents Background – Epidemiology – Transmission – Natural history

Clinical features of HIV – Diseases that define HIV infection – Clinical stadium

Opportunistic infections – Viral infections – Fungal infections – Parasitic infections – Bacterial infections

Immune Reconstitution Inflammatory Syndrome Other diseases related to HIV infection – Malignancy – Common co-infections

11/7/2013 Prodi S2 Ilmu Kedokteran Tropik

Minat Kedokteran Tropis Semester II 2012/2013 2

Minat Kedokteran Tropis 3

HIV/ AIDS Global Epidemy (Approximate numbers in 2012)

34.000.000 in the world

180.000 in Indonesia

3.500 in Jawa Timur

Discovery of HIV/ AIDS

Kluster kasus Kaposi’s sarcoma dan PCP pada orang gay di AS (1981)

Nama awal:

– Limfadenopati

– KS dengan infeksi oportunistik

– GRID (gay-related immune deficiency)

– 4H (Haitians, homosexual, hemophiliacs and heroin users) disease

US CDC: AIDS (1982)

Clinical Manifestation of AIDS prior to ARV Era

Co-discoverer of HIV Luc Montagnier*

Institute of Pasteur France Robert Gallo

National Cancer Institute USA

“LAV” “HTLV-III”

Francoise Barre-Sinoussi* Institute of Pasteur France

*Awarded Nobel Prize 2008

1985: AIDS is caused by HIV 1988: World AIDS Day (December 1)

HIV Replication Cycle

HIV Initial Infection and Dissemination

Induction of HIV-specific immune responses, beginning with CD8 + T cells and following

with antibodies that provide incomplete control of viremia

HIV Initial Infection and Dissemination

The stages and natural history of HIV infection

HIV-1 infection is divided into stages – primary infection with seroconversion – clinical latency – early symptomatic disease – AIDS.

The mode of acquisition: heterosexual transmission, MSM Risk factors for transmission include high plasma HIV viral load and presence of ulcerative genital sexually transmitted diseases. During the period of asymptomatic infection, patients generally have no findings on physical examination except for lymphadenopathy. Despite the lack of symptoms, high rates of HIV replication and CD4 T cell destruction may be occurring.

HIV Natural History

Conditions that define an AIDS diagnosis P. carinii pneumonia — 42.6 percent

Esophageal candidiasis - 15.0 percent

Wasting — 10.7 percent

Kaposi's sarcoma — 10.7 percent

Disseminated M. avium infection — 4.8 percent

Tuberculosis — 4.5 percent

Cytomegalovirus disease — 3.7 percent

HIV-associated dementia — 3.6 percent

Recurrent bacterial pneumonia — 3.0 percent

Toxoplasmosis — 2.6 percent

Immunoblastic lymphoma - 1.9 percent

Chronic cryptosporidiosis - 1.5 percent

Burkitt lymphoma - 1.5 percent

Disseminated histoplasmosis - 1.0 percent

Invasive cervical cancer - 0.9 percent

Chronic Herpes simplex — 0.5 percent 11/7/2013

Prodi S2 Ilmu Kedokteran Tropik Minat Kedokteran Tropis

Lymphadenopathy

ACUTE EXANTHEM OF HIV INFECTION

Opportunistic Infections

Pneumocystis jirovecii Pneumonia

CYTOMEGALOVIRUS INFECTIONS

HERPES SIMPLEX VIRUS INFECTIONS

Human papillomavirus

VARICELLA-ZOSTER VIRUS INFECTIONS

PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY

CANDIDIASIS

CRYPTOCOCCOSIS

ASPERGILLOSIS

Nontuberculous Mycobacterial Infections

TOXOPLASMOSIS

Tuberculosis in HIV

HIV infection is a potent risk factor for the development of active tuberculosis (TB).

This may result from: – high risk of reactivation of latent Mycobacterium

tuberculosis infection;

– increased risk of exposure to TB;

– greater risk of infection with M. tuberculosis following exposure to an infectious source;

– progression of M. tuberculosis infection to primary active TB.

SKIN INFECTIONS

Eosinophilic folliculitis

Kaposi’s Sarcoma

Non-Hodgkin’s Lymphoma

The Burden of HIV,HBV and HCV Worldwide

Estimated number in million.

HBV HCV

Worldwide prevalence of hepatitis and HIV

Infection Worldwide U.S.

HIV 31 million 860,000

Hepatitis B (chronic) 300 million 1 million

Hepatitis C (chronic) 170 million 4 million

Epidemiology

About 400,000 HIV/HCV + in U.S.

● overall 30-50% of HIV+ are co-infected

Prevalence of HCV in HIV+ individuals:

● approx. 90% in IVDU

● 60-85% in hemophiliacs

● 4-8% in HIV+ MSM

HIV/HCV Coinfection

Almost all HIV positive IDU are HCV coinfected

HIV/HCV100% (n=117) Iran

HIV/HCV 98% (n=131)Vietnam

HIV/HCV 99.3% (n=138) China

HIV/HCV 99% (n=131) Chiang Mai

Certain principles underlie the decision to use prophylaxis

the incidence and prevalence of specific infections in HIV-infected individuals the potential severity of disease in terms of morbidity and mortality the level of immunosuppression at which each disease is likely to occur the feasibility and efficacy of preventive measures, and in particular their impact on quality of life and survival the potential for emergence of organisms resistant to the agents used for prophylaxis the risk of toxicities and drug interactions with antiretrovirals and other drugs used by HIV-infected patients the issue of compliance the cost-effectiveness of prophylaxis.

DURATION OF PROPHYLAXIS AGAINST OPPORTUNISTIC INFECTIONS

Susceptibility to opportunistic infections can be accurately assessed by the CD4 + T-cell count stop primary or secondary prophylaxis in patients whose immunity has improved as a consequence of HAART and whose T cells have risen above the threshold of increased susceptibity

This is particularly true for patients with complete viral suppression, as ongoing improvements in immune function can be expected

IMMUNE RECONSTITUTION SYNDROMES

HIV-infected patients who initiate potent antiretroviral therapy with low CD4 T-cell counts, especially less than 100 cells/µL, are at risk for developing immune reconstitution inflammatory syndrome (IRIS) Opportunistic organisms, sometimes at high titer, may be present in HIV-infected hosts who are unable to mount immune responses to clear these pathogens. As immune responses are reconstituted on antiretroviral therapy, however, these microbes can stimulate profound immune reactions The presenting signs of IRIS are usually pathogen specific and relate to the tissues, organs, or compartments that are involved Distinguishing IRIS from clinical worsening of the underlying opportunistic infection can be challenging; cultures and biopsies sometimes help to clarify the picture. Treatment of IRIS may involve anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs or corticosteroids.

Nucleoside reverse transcriptase inhibitor-associated skin effects

Terima Kasih

HIV and Disease Related S01 IKT

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