User:Dr Munawar Khan

HIV/AIDS and Sindh, Pakistan

What is HIV/AIDS ? 
Sindh AIDS Control Program
Objectives
To create awareness of the seriousness of the disease Ensure that people of Sindh are equipped with knowledge and tools to protect themselves Reduce transmission of HIV and other STI infections through blood and blood products In case of infection, the patient should be encouraged to seek treatment  

Infra Structure and Services on Ground• Provincial Implementation UNIT (PIU) At I. I Depot, Rafique Shaheed Road near JPMC.• Referral Lab Established for laboratory diagnosis and confirmation of HIV/AIDS Cases & Sexually Transmitted Infections.• Voluntary Counseling & Testing centers 22 VCT Centers have been Established for screening of HIV/AIDS cases• STIs clinics 46 STIs Clinics have been Established at teaching and DHQ hospitals for management of STI,s• Establishment of Resource Center With Facilities of Digital Library. For trainees and projects staff• PPTCT Centers 03 (Prevention of Parents to Chid Transmission) PPTCT Centers of Pakistan Tertiary Hospitals:  PIMS- Islamabad  HMC- Peshawar  Lady Wallingdon- Lahore  Services- Lahore  Civil- Karachi  Qatar- Karachi  Shaikh Zaid Hospital Larkano  Sindamon- Quetta (nonfunctional)District Headquarter Hospitals:  DHQ Hospital, Gujrat  DHQ Hospital, DG Khan

Origin of HIV 
African Simean [Green] Chimpanzee 
History of HIV/AIDSHIV came from a similar virus found in chimpanzees - SIV.HIV probably entered the United States around 1970CDC in 1981 noticed unusual clusters of Kaposi’s sarcoma in gay men in NY and San Francisco, which led to the disease to be called GRID (Gay Related Immune Deficiency).By 1982 the disease was apparent in heterosexuals and was renamed AIDS (Acquired Immune Deficiency). 
1981 History 8 cases of Kaposis Sarcoma among young gay men June 5, 1981: 5 cases of PCP (Pneumocystis Pneumonia ) in gay men Los Angeles, San Francisco and New York, who had developed PCP ... (from UCLA (MMWR) collected by Dr MZ) 
Morbidity and Mortality Weekly Report (MMWR) MMWR SEARCH In the period October 1980-May 1981, 5 young men, allactive homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia at 3 different hospitals inLos Angeles, California. Two of the patients died. All 5 patients had laboratory-confirmed previous or current cytomegalovirus (CMV)infection and candidal mucosal infection.   

2006 HistoryUS National Institutes of Health revealedthe results of two African trials of malecircumcision as an HIV preventionmethod with clear evidence that theintervention reduced HIVtransmission by around 50%.+ The WHO and other organizationssuggested they would soon beginpromoting male circumcision in areaswith severe HIV epidemics. 13 collected by Dr MZ Global summary of the AIDS epidemic  2009Number of people Total 33.3 million Adults 30.8 millionliving with HIV Women 15.9 million Children (<15 years) 2.5 million Total 2.6 millionPeople newly infected Adults 2.2 millionwith HIV in 2009 Children (<15 years) 370 000AIDS deaths in 2009 Total 1.8 million Adults 1.6 million Children (<15 years) 260 000

Over 7000 new HIV infections a day in 2009 

 About 97% are in low and middle income countries  About 1000 are in children under 15 years of age  About 6000 are in adults aged 15 years and older, of whom: ─ almost 51% are among women ─ about 41% are among young people (15-24) 16. 16

HIV/AIDS in Pakistan

•Pakistan is going through a transition of the HIVepidemic; from a low Prevalence state to aconcentrated epidemic.•Although the estimated prevalence among thegeneral population is less than 0.1% in the country,• Recent surveillance results clearly indicate thatthe epidemic is becoming established amongcertain high risk groups (HRGs). Pakistan’s HIV epidemic•At present the most prominent face ofPakistan’s HIV epidemic are the IDUs.•In this regards, Pakistan is following the Asian Epidemic Model,•where the HIV epidemic first establishes amongIDUs and then spreads to the rest of the population via sexworkers who have sexual contact with IDUs. SUGGESTIVE HISTORY & RISK FACTORS RISK FACTORS/RISK BEHAVIOURS

People with multiple sexual partners• People with recent or prior STDs• Commercial sex workers & their partners• Homosexuals• Travelers to high prevalence areas• Sexually active injection drug users• Sexual partners of at risk persons• Recipients of blood products prior to HIV screening• Children born to HIV positive mothers 

But HIV/AIDS does not discriminate Everybody is vulnerable. The virus is not restricted to any age group, race, social class, gender, or religion. In many countries of Asia and the Pacific HIV/AIDS has spread to the general population. 20 Pakistan’s HIV epidemicA combination of risk factors is currentlyputting Pakistan at serious risk of furthertransmission from high to low risk groupsthrough bridging populations. 21 Example of high risk sexual networks in a populationFSW Male Clients IDU General Population MSW Women

HISTORY OF HIV IN PAKISTAN • 1986 – An African Sailor Died in Karachi• 1987 – First Pakistani Citizen Diagnosed with AIDS in Lahore• 1987 – First Husband-Wife-Child transmission of HIV occurred in Rawalpindi• 1993 – First Breastfed Baby gets AIDS in Karachi• 2003 First outbreak among Injecting Drug Users was identified in Larkana 24

HIV & AIDS in Pakistan (2nd Quarter 2010)• Total Estimated Cases = 106000• Total reported HIV & AIDS cases in the country are = 7574• HIV Positive – 7049• AIDS Cases – 525

HIV/AIDS IN SINDH PAKISTAN 

SINDHUpto September 30,2011TOTAL CASES = 4325 HIV Asymptomatic Cases = 4130 Male = 3885 94.07 % Child = 23 0.56% Female = 205 4.96% Child = 17 0.41%AIDS CASES = 195 Male = 164 (84.10 %) Child = 01 (0.51%) Female = 29 (14.87) Child = 01 (0.51%) DEATH CASES TILL30th September 2011DEATH = 140Male = 122 87.14%Child = 02 1.43%Female = 10 7.14%Child = 06 4.29% 28

Sindh is in the concentrated phase of epidemic among :• IDU’s = 27%• Hijra Sex workers =15.45% 29 

• HIV epidemic is still considered ‘low’ or ‘concentrated,’ confined mainly to individuals who engage in high risk behaviors,• An epidemic is considered ‘concentrated’ when less than one per cent (1%) of the general population but more than five per cent(5%) of any ‘high risk’ group are HIV- positive• An epidemic is considered ‘generalized’ when more than one per cent of the population is HIV-positive.

HIV  

-H Human -I Immunodeficiency -V Virus

HIV ?• HIV is different from most other viruses because it attacks the immune system• The immune system gives our bodies the ability to fight infections.• HIV finds and destroys a type of white blood cell WBC (T cells or CD4 cells) that the immune system must have to fight disease.• People can live a long healthy life with HIV without symptoms, even without medications.• Once the immune system begins to break down over time, and the person develops more symptoms,• This often means they have progressed to AIDS.Caused by immune deficiency virus• HIV-1• HIV-2 

Genetic Subtypes of HIV• Groups : HIV 1 , HIV 2• Genetic subtypes : Groups : HIV 1- M(main),O(outlier),N (new) Subtypes(clades) M(11 subtypes A-I,CRF) HIV 2—Six subtypes A-F

DIFFERENCE B/W HIV-1 & HIV-2• 

HIV-1 and HIV-2 are closely related, they are thought to have jumped from primates to humans at different times (and from different species).• HIV-1 is more easily transmitted, it also spreads more readily and therefore accounts for the vast majority of global HIV infections.• HIV-2, is much less transmittable, is largely confined to West Africa (where it is thought to have originated) and to West African migrant communities in Europe. • HIV-1 also mutates more efficiently that HIV-2 and generally progresses to AIDS at a significantly faster rate than HIV-2 does.• Also, HIV-2 has Vpr and Vpx proteins. HIV-1 has only Vpr.• Differences between these proteins are actually on research. 40 38. HIV-1 and HIV-2 Infections• HIV-2 has the same genetic organization as HIV-1 but there are significant differences in the envelope glycoprotein• Similar diseases associated with both HIV-1 and HIV-2 but most west Africans remain asymptomatic• Progression from HIV to AIDS is faster in HIV-1 as compared to HIV-2, either it is less pathogenic or it has a long period of latency• HIV-2 infected children have far better survival rates VIROLOGY / LIFE CYCLE• HIV is a retrovirus belonging to the family of Lentivirus• Able to use the RNA and the host DNA to make viral DNA• Long incubation period/Clinical latency THE HIV LIFE CYCLECONTINUOUS VIRAL REPLICATION LEADING TO IMMUNODEFICIENCY IS THE HALLMARK OF THE DISEASE!! The Immune System T Cells (CD4 Cells) = Part of body’s immune system CD4 The average person has between 800 & 1500 CD4 cells per cubic millimetre of blood The immune system helps fight diseases CD4 Disease Disease IMMUNE ATTACKS DISEASE KILLS DISEASE SYSTEM HIV and the Immune SystemWhen HIV enters the body it must enter a cell to live and reproduce. The HIVvirus attacks CD4 cells, eventually killing them CD4 HI HIV V HIV HI CD4 V HI V HIV Enters CD4 Cells HIV Replicates Kills CD4 CellsThe newly produced HIV then moves into new CD4 cells and infects them.The body’s immune system tries to replace the lost CD4 cells, but overtime it is unable to keep these levels up.

HIV-Infected T-CellHIV HIV Infected New HIV T-Cell T-Cell VirusVirus 

VIROLOGYgp 120 & gp 41 have the major role to recognize CD 4 cells thus promoting attachment

HIV Replication• HIV is a retrovirus.• Viral envelope protein gp120 and gp41 attach to the CD4 antigen complex on host cells• CD4 found on T helper lymphocyte,B lymphocytes, monocytes and tissue macrophages.• HIV uses RT to convert RNA to DNA• HIV DNA enters nucleus of CD4 cell and integrates into host DNA.• HIV DNA instructs cell to make copies of original virus.• New virus particles are assembled and leave cell, ready to infect other CD4 cells. 
Viral RNA yellow,DNA blue Reverse Transcription Attachment Entry of the Viral RNAReverse TranscriptaseInhibitor (red) Integration of Viral DNA Transcription: Back to RNA Translation: RNA -> Proteins Protease Inhibitors Viral Protease Assembly and Budding 
HIV Transmission• HIV enters the bloodstream through: – Open Cuts – Breaks in the skin – Mucous membranes – Direct injection 
MODES OF TRANSMISSION• Blood/Blood products, tissues, organs- More than 90%• Sexual Intercourse - 0.1 to 1% (however frequency is high causing high rate of infection)• IDU – 0.5 to 1 %• Parent to child – 30% 53 

HIV Modes of Transmission1. Sexual2. Infected blood and blood products3. Mother to Child

HIV Modes of Transmission Cont’d…1. Sexual: • Through sex with infected man or woman. • Transmit by Hetrosexual & Homosexual and Bisexual Practice • Ulcerative STIs increases the risk of infection several folds 

. HIV Modes of Transmission Cont’d…2. Infected blood and blood products • Contaminated Blood/Blood Products transfer • Organ/Tissue Transplants • Use of Contaminated Syringes and Needles • Tattooing • Ear piercing etc.

HIV Modes of Transmission Cont’d…3. From mother to child (Vertical) • Pregnancy • Delivery • Lactation 
HIV/AIDS Interflow Communications 
Press ad Option 1 59 
How you catch up HIV?• The virus spread from human to human by body fluids : Blood, Semen, female vagina fluids and mother milk.• HIV do spread in full sexual Intercourse that include penetration to female vagina or the rectum without the use of Condom, and that’s because its lives within the human fluids, as mention above.• HIV also do spread by using common needle, because AIDS lives in the blood, due to that fact, drugs addict are extremely vulnerable for HIV infection.• HIV is spreading by a breast feeding, because it can live within mother milks. 
HIV Transmission • Common fluids that are a means of transmission: – Blood – Semen – Vaginal Secretions – Breast Milk – Saliva 
How can you get HIV?. Through these bodily fluids VAGINAL ,BREAST SECRETIONS, MILK, BLOOD , SEMEN. 

Through these acts: UNPROTECTED PENETRATIVE INTERCOURSE (HOMOSEXUAL OR HETEROSEXUAL) INJECTION OR TRANSFUSION OF INFECTED BLOOD/ BLOOD PRODUCTS . SHARINGof UNSTERILISED NEEDLES WITH Some one, Child Birth of Infected Mother, BREAST FEEDING Quantity of HIV in Body Fluids Blood 18,000 ,Semen 11,000, Vaginal Fluid 7,000, Amniotic Fluid 4,000 Saliva 1 Average number of HIV particles in 1 ml of these body fluids.

TRANSMISSION RISK AFTER EXPOSURE• 95% for blood and blood products•15-40% for vertical transmissionPPTCT• 0.5% -1.0% for injection drug use IDU• 0.2-0.5% for  genital mucous membranes•< 0.1% for non genital mucous membranes• Needle stick injury : 1 in 300 World wide major route of transmission Heterosexual(70%) Transmission 
Estimated PPTCT Rates Without intervention During pregnancy 5–10%During labor and delivery About 15%During breastfeeding 5-20%MTCT infection rates = up to 40% 
HIV Routes of Transmission Sexual Contact: Male-to-male Male-to-female or vice versa Female-to-female Blood Exposure: Injecting drug use/needle sharing Occupational exposure Transfusion of blood products Parental: Transmission from mother to baby Pregnancy, delivery and breastfeeding 
HIV Infection and Antibody Response ---Initial Stage--Intermediate or Latent Stage--Illness Stage--- Flu-like Symptoms Or Symptom-free AIDS Symptoms No Symptoms ----Infection Virus Occurs Antibody ---- < 6 month ~ Years ~ Years ~ Years ~ Years 
Natural History of HIV Infection: 
Window Period• This is the period of time after becoming infected when an HIV test is negative• 90 percent of cases test positive within three months of exposure• 10 percent of cases test positive within three to six months of exposure 
Infections in relation to CD4+ cell count400 Herpes Zoster Tuberculosis300 Oral Candidiasis200 PCP Esophageal Candidiasis A Mucocutaneous herpes100 I Toxoplasmosis Cryptococcosis D (Mycobacterium avium complex ) MAC (Cytomegalovirus) CMV50 S (Progressive Multifocal Leuko encephalopathy) PML Cryptosporiodiosis Time 
AIDS 

• A- Acquired • I- Immunity • D- Deficiency

• S- Syndrome
It destroys the immune system of infected person. 
After HIV infection (without ARV) • Most will develop AIDS 8-10 years later 

• 5-10% will develop AIDS first few years • 5-10% will not progress to AIDS for 15 or more years Evaluation DR M MUNAWAR KHAN BCC COORDINATOR SINDH AIDS CONTROL PROGRAM PAKISTAN Health Department, Govt. of Sindh

SINDH PAKISTAN