HIVAIDS Introduction to HIV Disease and AIDS What

HIV/AIDS Introduction to HIV Disease and AIDS

What is HIV? n n HIV stands for the Human Immunodeficiency Virus : Can only infect humans Virus attacks the Immune System making it weaker Virus, antibiotics don’t work

What is AIDS ? AIDS stands for Acquired Immune Deficiency Syndrome: n Acquired – must contract it, not genetic n Results from a weakened immune system n Syndrome – collection of symptoms n

HIV vs. AIDS: What’s the Difference? n n HIV Disease consists of 5 basic stages, of which AIDS is the final stage To be diagnosed with AIDS, an individual must be HIV+ and…. Have a special infection or cancer that only affects those with severely weakened immune systems: OPPORTUNISTIC INFECTIONS n

CD 4 cell (T-cells) n n The “quarterback” or “brain” of the immune system: it coordinates your body’s response to infections The cell that HIV targets, infects, and kills” “Normal” range can be anywhere from 500 -1500 CD 4 cells per teaspoon of blood A routine blood test for PHAs to assess immune function (~every 3 months) HIV CD 4 Cell

Viral Load n n n Refers to the amount of HIV in an individuals blood Amount can vary over time and with HIV medicine Goal of treatment is to reduce the viral load to “undetectable”. Even at the undetectable level, the virus is still present in “reservoirs” like the lymphatic system and some organs. “Undetectable” range is less than 50 copies of virus per mm 3 A routine blood test for PHAs to assess when to start treatment, assess treatment effectiveness

1. Primary Infection (Acute) 2. Seroconversion 3. Asymptomatic Infection 4. Symptomatic Infection 5. AIDS

Primary (Acute) Infection 1. Virus multiplies rapidly 2. CD 4 cell count drops during this period and Viral Load can be very high as the body has not yet responded to the infection 3. Individual may test negative for HIV antibodies, but VIRUS IS EASILY TRANSMITTED

CD 4+/Viral Load: HIV Disease

Seroconversion • The point when the body begins to create antibodies to HIV • Usually occurs within 3 months of acute infection (95% will seroconvert by 2 mos, 99% by 3 mos) • Individual will now test positive for the HIV antibody test. • Some individuals report a flu/mono-like virus at this stage, though it is rarely “caught” by doctors.

Possible Signs of Recent HIV Infection: n Rash and/or fevers possibly in combination with: n Malaise, loss of appetite, weight loss, sore throat, mouth sores, joint pain, muscle pain, swollen lymph nodes, diarrhea, fatigue, night sweats, nausea/vomiting, headache, genital sores n If you have these symptoms it doesn’t mean you are HIV positive If you don’t have/never had them it doesn’t mean you are HIV negative n n n NOT ALL PEOPLE EXPERIENCE THESE SYMPTOMS, but if you have engaged in any activity that may have put you at risk (even if you think your partner is HIV negative) and you experience some of these symptoms, GO GET AN HIV TEST! The earlier a person is diagnosed the less likely they are to pass on their infection and the earlier they can begin accessing medical care

Asymptomatic Infection (no symptoms) n n Refers to a period where there is little/no symptoms Even without symptoms, HIV is still multiplying and the body is still fighting the infection CD 4 cells are decreasing slowly, while HIV is increasing slowly Up to and including this stage, an individual may have no symptoms of infection! That is why 30% of HIV+ people are unaware that they are infected!!!!!!

The Silent Battle…. .

Symptomatic Infection • as an individual’s immune system is weakened, they may develop “whole body” symptoms including: night sweats, fever, diarrhea (1 mo. +), significant weight loss, fatigue, chronic yeast infections, frequent cold/flu • at this time, CD 4 cell count is dropping,

CD 4+/Viral Load: HIV Disease

AIDS • the final stage of HIV disease • Immune function is severely damaged, practically non-functional • When an HIV+ person develops one or more of the 30+ different Opportunistic infections, s/he is said to have AIDS

HIV Treatment n n n HIV meds can reduce the amount of HIV in the blood to an undetectable (but still present) level which allows the body’s CD 4 cells to replenish to a “healthy” level. Undetectable viral load reduces the likelihood of transmission Until late 2009, guidelines suggested people start meds between 200 -350 CD 4 cell count and this can basically prolong (possibly indefinitely) the asymptomatic phase. (most major, life threatening OIs occur at <200 CD 4 cells) New guidelines suggest starting treatment earlier. Physicians should offer treatment at 500 and strenuously suggest treatment at 350. 50% of the expert panel thought offering treatment above 500 was warranted, the other 50% thought it was optional. Adherence must be greater than 95% to prevent virus from becoming resistant to the medications (right dose, right time, right amount of food/no food). Side effects to treatment can be serious and difficult to endure ,

HIV Transmission

Transmission Basics n n Canadian AIDS Society (CAS) Transmission Guidelines There are certain basic conditions necessary for transmission to occur: n n n Source of infection Means of transmission Host susceptible to infection Route of entry to target cells of the body Sufficient level of virus delivered to establish infection

Body Fluids (cont’d) Not all body fluids can transmit HIV n The ONLY body fluids that can transmit HIV are: n BLOOD n SEMEN n VAGINAL FLUIDS n RECTAL FLUIDS n BREAST MILK n

HIV Transmission Equation n There are certain things that must be in place for HIV to transmit from one person to another. It is sometimes called the TRANSMISSION EQUATION HIV + Body Fluid • Blood • Semen • Vaginal Fluids • Rectal Fluids • Breast Milk Means of Transmission • Sexual Transmission • Sharing Needles and Works • Mother to Child Entry Into the Body • Break in the Skin • Mucosal Lining Contact** • Direct Contact with Blood Stream (IV) Possible HIV Transmission

Mucous Membranes (MMs) n Form the surface of body cavities n n n (nostrils, vagina, anus, mouth, throat, respiratory/digestive/reproductive systems) MMs cover 400 m 2 surface area (1 and ½ tennis courts) It is wet, and in some places, secretes mucous that helps keep out foreign invaders Lined by an epithelium (protective layer of cells); similar to skin but alive Many immune cells within and right below the surface of MMs to protect against possible infection Since HIV can infect immune cells, it provides many targets for HIV in exactly the areas of the body that it will contact

ANUS/RECTUM • Many immune cells in the anus, rectum, and large intestine to protect against high number of invaders • Easier for HIV to find a target • Epithelium of rectum is only 1 cell thick, so it is easier to get through • Large surface area • Lots of room for HIV to come into contact with an immune cell

FEMALE REPRODUCTIVE TRACT – Vagina, Cervix, and Uterus n n HIV can transmit through any part; but most easily through the cervix Vaginal wall has multiple overlapping layers of epithelial cells, so it is a bit harder to cross Epithelium in the upper part of the cervix and uterus is 1 cell thick, like the anus, so it is more vulnerable to HIV and STIs Many immune cells naturally present at cervix to protect a potential fetus

THE UNCIRCUMCISED PENIS n The urethra is lined with mucous membrane n The area under the foreskin is a mucous membrane with lots of dendritic cells*

MOUTH AND THROAT n n n Saliva has a MUCH lower viral load than blood or genital fluids Activities involving the mouth are generally considered low risk activities Oral mucosa is tough and quick to heal Tonsils are most vulnerable to HIV Risk increases with ejaculation, menstruation, poor oral health, or inflammation

Role of Inflammation n n Body’s immune response to injury, irritation, or infection by foreign object/organism Causes: n n Redness and heat : increased blood flow which brings immune cells to the region Localized swelling as walls of blood vessels become thinner : allows more immune cells to migrate from the blood into the MM to find invaders

Inflammation n ANYTHING that increases inflammation increases and HIV+ person’s chance of transmitting it to someone else, AND increases an HIV- person’s vulnerability to infection n Infl. increases viral shedding in genital/rectal tracts of HIV+ persons Some proteins in immune response increase ability of HIV to reproduce Activated target cells (CD 4, macrophage, dendritic cell) come to the area and have increased chance of contact with HIV

INFLAMMATION – Influx of Immune Cells

Biological Factors in HIV Transmission n n What bio. factors increase the infectiousness of an HIV+ person? Viral Load in semen, vaginal fluids, anal fluids n n Affected by changes in blood VL, coinfection with an STI, inflammation, or stage of HIV disease HIV+ people are more likely to transmit in the first 5 months after being infected n Astronomically high VL, unaware of infection, sexually active, sometimes with multiple partners

HIV and Women n n n It is 4 -6 x easier for a man to infect a woman, than vice versa: Vagina is very large mucosal area Semen has, on average, a higher viral load than vaginal fluids Up to 75% of some STIs show no symptoms in women (vs. 40% in men), women are more likely to be infected and be unaware Socio-economic factors can make women more vulnerable to infection Women are not being educated about their increased risk for HIV infection in schools

Transmission Basics n n CAS categorizes activities into risk levels: No risk, Negligible Risk, Low Risk, High Risk n n n 1. Is it theoretically possible? (exchange of body fluids) 2. Have their been documented cases? How many? Helps people make knowledgeable choices as to how much risk they are willing to take HOWEVER: Quantifying risk is very difficult and these categories are not clear or absolute HIV risk is a continuum based on various social and biological vulnerabilities, as well as the infectiousness of the HIV+ partner

High Risk Penile – Vaginal Sex (without condom) n Penile – Anal Sex (without condom) n Receiving shared sex toys n Injecting with shared needles n

Low Risk Kissing (with exchange of blood) n Performing fellatio/cunnilingus (no barrier) n Vaginal/Anal Sex with a condom n Injecting with cleaned needles n Tattooing with non-professional equipment n Taking blood in the mouth n Occupational Exposure n

Negligible/Theoretical Risk n n n n n Receiving fellatio/cunnilingus Performing fellatio/cunnilingus with barrier Anilingus Fingering, fisting Vulva-vulva rubbing Docking Taking breast milk into the mouth Using drugs with shared pipe or straw Sharing toothbrushes/razors Fighting

No Risk Kissing (no visible blood) n Non-insertive masturbation n Receiving unshared sex toys n Injecting with new needles n

What ↑ Risk for Sexual Transmission? n n n Sexually Transmitted Infections*** Imbalance of natural vaginal/anal bacteria n Eg. Bacterial vaginosis, BV Anything that causes inflammation of mucous membranes n n n Increases an HIV+ persons chance of transmitting HIV Increases a person’s vulnerability to HIV infection Dryness of mucous membranes Sex Hormones Immature cervix (pre-puberty up to 18 years) Sexual transmission of HIV is complex; it is practically impossible to assess the specific risks for an individual….

HIV and Sex n n n Anal Sex (penile-anal) With a condom…. low risk Without a condom…high risk (for both receptive and insertive partner) Transmission via mucous membrane in rectum and on penis (urethra and foreskin) Current STIs greatly increase likelihood of transmission as it may provide a portal of entry for HIV to access the bloodstream

HIV and Sex n n n Vaginal Sex (Penile-Vaginal) With a condom…. low risk Without a condom…high risk (for both receptive and insertive partners**) Easier for an HIV+man to infect a woman due to large vaginal mucosa, higher concentrations of HIV in semen (compared to vaginal fluids), and many STIs in women can be asymptomatic Foreskin = increased risk for HIV? ? ? Pulling out before ejaculation? ? ?

HIV and Sex Oral Sex (mouth-penis, fellatio) n Performing n With condom…Negligible Risk* n Without condom. . Low Risk n n Receiving n With/Without condom… Negligible Risk

HIV and Sex n n n n Fellatio cont’d The performer is at risk because pre-cum or semen can get into the mouth The mouth is a generally hostile environment for HIV Risk is increased if there are disruptions in oral mucosa (bleeding gums, cuts, sores, lesions, ulcers, burns, recent dental work) Wait at least 30 minutes to 2 hours after brushing or flossing, eating food that can irritate oral mucosa Swallowing? ? ? Receiving fellatio, negligible risk

HIV and Sex n n n Oral Sex (mouth-vagina, cunnilingus) There is a risk because vaginal fluid and blood can get in the mouth ( which is generally a hostile environment for HIV) Increased risk with oral mucosa disruption Higher risk during menstruation because of the presence of blood Wait 30 min – 2 hours after brushing/flossing Receiver is at negligible risk

HIV and Sex n n n Oral Sex (mouth-anus, anilingus) Not an efficient means to transmit HIV There is a potential for transmission if blood is present in or around the anus Receiver is at negligible risk However, anilingus is efficient at transmitting other STIs (syphilis, gonorrhea, hep A and B, and intestinal parasites)

Testing for HIV The name of the test is the HIV Antibody Test. n It does not test for the presence of the virus itself…. n It tests for the presence of your bodies response to the virus (seroconversion) n

Testing cont’d n n There is a “Window Period” of time after the infection but before your body responds by producing antibodies. 95 % of people’s bodies will respond by 2 months after infection with HIV 99 % will test positive at 3 months New research!

ANONYMOUS TESTING n n n n Highly recommended Person providing the test does not know your name (unless you give it to them) Test is sent away with a code number that only you know, and therefore the lab does not know your identity If the results are positive, you are responsible for partner notification, but you can ask for help if you want Test results are not included on your health record or file. Pre Test and Post Test Counselling! Possible Future Ramifications

The HIV test: A Closer Look n n n HIV antibody test Blood is drawn and sent to the lab The first test done is the ELISA/EIA test (screening test) n It is highly sensitive…it catches everyone* who may be positive n A repeatedly negative/non-reactive ELISA is considered to be accurate and no further testing is done…if positive…. Second test (Western Blot) is the confirmatory test n Highly specific test that is positive only* when the person is actually positive Taken together these tests are EXTREMELY accurate (within the window period) n The majority of the few false negatives occur due to window period issues, though there are other causes.

Where can I get tested? n Sexual Health Clinic (new location) 600 Southgate Dr, Guelph 519 -846 -2715 n AIDS Committee of Guelph Check www. aidsguelph. org for upcoming dates n RAPID TESTING IS AVAILABLE AT EITHER LOCATION