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HIV/AIDS – CLINICAL MANAGEMENT

HIV/AIDS – CLINICAL MANAGEMENT. Dr.K.BUJJI BABU,. MD.,STD, HIV/AIDS & Skin. Dr.Bujji Babu HIV Clinic. Suryaraopet, Vijayawada. GOALS. Opportunistic infections Antiretroviral treatment Mother-to-Child Transmission Psychosocial issues Ethics. HIV TRANSMISSION. Exchange of body fluids

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HIV/AIDS – CLINICAL MANAGEMENT

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

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

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

  4. WHO Classification • Major signs - Weight loss >10% of body weight - Fever more than one month int & cont - Chronic diarrhoea more than one month intermittent and continues

  5. 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

  6. CDC REVISED CLASSIFICATION • CD4 T-cell A B C >500/ul A1 B1 C1 200-499/ul A2 B2 C2 <200/ul A3 B3C3 A- Asymptomatic or PGL B- Symptomatic C – AIDS indicator

  7. CLASSIFICATION (CD4) • CD4 cell count/ul Stage of HIV disease >500 Early 500 – 200 Intermediate 200 – 50 Late or severe <50 Far Advanced

  8. 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

  9. COURSE OF HIV INFECTION • Acute seroconversion syndrome in 1/3rd • Phase of clinical latency • CD4 <200/ul, OI begins to set • Progress to AIDS about 8-10 yrs

  10. 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

  11. OPPORTUNISTIC INFECTIONS - DIARRHOEA • Parasitic – Criptosporidium, Isosporabelli Microsporidia, Giardia, EH • Bacteria – Solmonella, Campylobacter, C.difficile, M.tuberculosis

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

  13. EMPIRIC ANTIBIOTIC RX • TMP/SMX • Ciprofloxacin • Metronidazole • Paramomycin

  14. COUGH & FEVER • Acute – WBC + abundant bacteria • Sub acute – Few WBC – PCP • Chronic – AFB+ - TB • Malaria, Typhoid, Viral fever • Crypto • Toxo

  15. CNS MANIFESTATIONS • Cryptococcal meningitis • Toxoplasmosis • Tuberculous meningitis • Progressive multi focal leukoencephalopathy • Neurosyphilis • Lymphoma

  16. 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

  17. PULMONARY MANIFESTATIONS • Pansinusitis • Pulmonary or extra pulmonary tuberculosis • PCP • CMV

  18. CUTANEOUS MANIFESTATIONS • Infectious dermatoses Viral infections Acute HIV, HSV, VZV EBV HPV

  19. BACTERIAL INFECTIONS • Staphylococcal • Mycobacterial • Bacillary angiomatosis • T.Pallidum infection • Others – Pseudo, salmo, nocardia

  20. FUNGAL INFECTIONS • Superficial dermatophytosis • Candidiasis • Superficial mycoses • Deep infections & systemic mycoses Crypto, histo, coccidio, sporotrichosis, penicilliosis, blastomycosis, aspergillous

  21. PARASITIC INFECTIONS • Arthropod infestations Scabies, demodicidosis • Protozoal infestations Ex-pulmonary pneumocystosis, leishmaniasis, cutaneuous toxo, acanthamoebiasis

  22. NON-INFECTIOUS DERMATOSES • Seborrheic dermatitis, psoriasis, Reiter’s, ichthyosiform dermatoses • Papular and follicular eruption of HIV • Pigmentary idsorders • Adverse cutaneous drug reactions • Neoplasms: Kaposi’s, lymphoma, melanoma

  23. 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

  24. STIs & HIV • Severe/extensive • Atypical/chronic • No response/minimal response to standard Rx • Precocious syphils • TPHA & FTA – ABS – Positive

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

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

  27. OCCULAR MANIFESTIATIONS IN HIV • Conjunctivitis • Karatitis • CMV retinopathy • TB retinopathy • Sudden retinal detachments

  28. ENT MANIFESTATIONS IN HIV • Oropharyngeal candidiasis • Middle ear disorders • Pan sinusitis

  29. RENAL MANIFESTATIONS IN HIV

  30. 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

  31. HAEMATOLOGICL DISORDERS IN HIV • ANAEMIA

  32. CVS IN HIV • Atherosclerosis due to CMV • Cardiomyopathy due to CMV • Cardiomyopathy due to anaemia • CCF

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

  34. PAEDIATRIC HIV • Diagnosis based on antibody tests >18 M • Immediate diagnosis – antigen test DNA PCR, p24 antigen

  35. ANTI-RETROVIRAL THERAPY • Clinical goal • Virological goal • Immunological goal • Therapeutic goal • Epidemiological goal

  36. INDICATIONS FOR ART • Acute infection • Symptomatic • Asymptomatic - CD4 <200 to 500 - HIV RNA >20,000 copies - RT-PCR >10,000 copies bDNA

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

  38. COMBINATION OF ART • Mono therapy • Duel therapy • Highly active antiretroviral therapy • Salvage therapy (rescue therapy) • Recycling therapy • Mega-HAART • Subtraction regimen (step down therapy)

  39. 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

  40. 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

  41. PSYCHOSOCIAL MANAGEMENT • Counseling - Relationship building - Assessment - Goal setting - Intervention - Termination & follow up

  42. 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.

  43. 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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