Question

A 25 year old female visits her general practitioner because she has been losing a lot of weight without trying, and has also noticed that she has been getting repeated sinus infections, as well as a fungal infection in her mouth, over the past several months. Her doctor runs a blood test and determines that the patient is HIV positive.

1. The doctor asks the patient about her medical history, including the number of sexual partners she has had. The patient tells the doctor that she has severe anemia, and therefore has required several blood transfusions throughout her lifetime. She also tells her she has had 10 sexual partners over the past 7 years. What are the two possible transmission routes that this patient could have contract HIV from?
2. The doctor runs further tests to determine the patients T cell count, and notes that it is 180 helper T cells per microliter of blood. Would this patient be diagnosed with AIDS?
3. Explain, in detail, the progression of HIV/AIDS. Be sure to include the three stages and a description of the general levels of HIV RNA and helper T cells at each stage.
4. What treatment would the doctor likely recommend for the patient?

Answer 1

In the present case study, 25 year old famale visits the hospital with problems of

• Unintentional weightloss
• frequent sinus and fungal infection in mouth for months

She had the history of anemia and multiple blood transfiusion

the patient revelaed that she has multiple sexpartners including 10 over the past 7 years

She had 180 helper T cells per microliter of blood

1 POSSIBLE WAY OF TRANSMISSION OF HIV TO THE PATIENT

• both sexual trnasmission and transmission OF HIV through blood can be suspected in the patient
• She had history of anemia and had multiple sex partners in relationship
• Sexual transmission by Intercourse (penile penetration into the vagina) ,Oral,Anal and Digital Sex
• Sharing the needles of an HIV patient also can be a cause

2. Diagnosis of HIV

• T cells,Also known as CD4 cells  are white blood cells that fight infection and play an important role in the immune system.
• HIV virus attacks and destroys CD4 cells and reduce the ability for immunity and will have trouble fighting off infections
• When HIV enters CD4 cells for reproduction, it damages the CD4 cell, eventually killing it.
• Normal CD4 count is 500–1,200 cells per cubic millimeter
• In the present case study it is 180, which interprets the decresed number of T cells
• It is a contributiory evidence for HIV infection

3. Progreesion of HIV

Early stage

• Patient able to perform normal activity normal activity during this stage
• HIV identification during this stage  lowers the amount of virus in the body, which allows the immune system to strengthen and helps prevent illnesses from occurring.
• Starting HIV treatment in this early phase help in preserving the immune system.

CLINICAL STAGE I

• Although HIv virus start to act in the body, there will not be any symptoms present outside
• there will be  slightly different system of the CDC, but will be maintained above 500
• The viral load test will usually show that the virus is replicating during this phase
• Persistent generalized Lymphadenopathy may be present

CLINICAL STAGE II

• Unintentional weight loss < 10% may be prsent
• Minor mucocutaneous manifestations occurs during this stsge
• Recurrent upper respiratory tract infections may present
• Other Symptoms may include skin disorders, prolonged diarrhoea, night sweats, thrush, bacterial pneumonia, fatigue, joint pain, and weight loss
• symptoms may be present but nearly fully ambulatory
• In the CDC system, it corresponds with stage 2, that is CD4 count between 200 and 500 will be present
• Eventhough the patient already had HIV for several years by taking treatment , It will strengthen your immune system, reduce the amount of HIV in your body and prevent illnesses from occurring.

CLINICAL STAGE III

Common symptoms includes,

•   Chronic diarrhea will be present
•   Oral candidiasis
• Unintentional weight loss >10%
• Prolonged fever more than a month
• Vulvovaginal Candidiasis
• Oral hairy leukoplakia
• Severe bacterial infections
• Pulmonary tuberculosis
• CDC system, it is stage 3 (a CD4 count below 200).

CLINICAL STAGE IV

• This is chronic stage of the disese
• The CD4+ cell count is less than 200. in this stage
• symptoms willbe seveere and sometimes life threatening

4. TREATMENT

1.Antiretroviral therapy

Goals of therapy

• Improve quality of life
• Reduce HIV-related morbidity and mortality
• Restore and/or preserve immunologic function
• Maximally and durably suppress HIV viral load
• Prevent HIV transmission

Guidelines for when to start ART

• Potent ART may improve and preserve immunefunction in most patients with virologic suppression, regardless of baseline CD4 count
• ART indicated for all with low CD4 count or symptoms
• Earlier ART may result in better immunologic responsesand better clinical outcomes

1. Reduction in AIDS- and non-AIDS-associated morbidity and mortality
2. Reduction in HIV-associated inflammation and associated complications
3. Reduction in HIV transmission

• Recommended ARV combinations are considered to bedurable and tolerable
• Exact CD4 count at which to initiate therapy not known, but evidence points to starting at higher counts
• Current recommendation: ART for all patients with CD4 <500 cells/µL
• For patients with CD4 >500 cells/µL, 50% of the panel recommend ART, 50% consider ART to be optional

Mechanism of action of anti retro viral agents

1. Entry Inhibitors:

- Prevent HIV from entering healthy T cells in the body

- enfuvirtide(Fuzeon)

2.Reverse Transcriptase Inhibitors

i. Nucleoside reverse transcriptase inhibitors

 (NsRTIs)Incorporate into viral DNA terminating its construction E.g. Lamivudine - Abacavir

ii. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI’s)

 Action is similar to NRTI’s; bind directly to reverse transcriptase , E.g. Nevirapine

3. Reverse Transcriptase Inhibitors

iii. Nucleotide Reverse Transctriptase Inhibitors (NtRTI’s) , E.g. Tenofovir

4. Protease Inhibitors (PI’s)

• Prevent assembly & release of new virus particles , E.g Ritonavir - Saquinavir

5.  Integrase inhibitors

 work by disabling a protein called integrase, which HIV uses to insert its genetic material into CD4 T cells. , E.g raltegravir

Antiretroviral Agents Regimen

All recommended regimens for initial treatment contain an NNRTI, a ritonavir-boosted PI, or an INSTI in combination with tenofovir (NtRTI) and emtricitabine (NRTI).

The preferred agents are as follows:

1. NRTI/NtRTI combination: Tenofovir and emtricitabine

2. PIs: Atazanavir/ritonavir

3. NNRTI: Efavirenz

4. INSTI: Raltegravir

Evaluation of treatment

 Criteria

• HIV RNA (viral load) in blood
• Count of T cells
• Appropriate clinical response

 Treatment Failure

• viral load with low T-cell count
• Clinical deterioration
• New opportunistic infections

TREATMENT

FOR HIV ASSOCIATED GINGIVITIS (HIV-G) AND HIV ASSOCIATED PERIODONTITIS (HIV-P)

• Gingival and periodontal diseases (NUG&NUP) - first sign of HIV infection.
• Gingivitis in HIV infected children appears as an intensely erythematous band that extends 2 to 3 mm apically from the free marginal and attached gingiva.

Treatment

• Aggressive curettage , Peridex (0.12 %chlorhexidine digluconate) rinses 3 times daily , Antibiotic treatment
• In cae of periodntitis , Drugs like Zidovudine can be given but usually used.
• For oral ulcers,
• Fluconamide ointment (0.5%) , Orabase 3-6 times/day , Dexamethasone 0.5 mg/ml are used as modalities of tratment