Immunodeficiency and HIV/AIDS

Immunodeficiency

• Immunodeficiency increases susceptibility to infections, cancers, and diseases that healthy immune systems can typically fight off.
• Types of immunodeficiency include:
  • Ataxia-telangiectasia
  • AIDS
  • Complement deficiencies
  • Chediak-Higashi syndrome
  • DiGeorge syndrome
  • Hypogammaglobulinemia
  • HIV
  • Job syndrome
  • Leukocyte adhesion defects
  • Combined immunodeficiency disease

History of HIV Discovery

• In 1983, Luc Montagnier considered a virus as a potential cause.
• Montagnier partnered with Francoise Barre-Sinoussi and discovered a retrovirus in cells from AIDS patients.

Cut Hunter Hypothesis

• The cut hunter hypothesis originated from chimpanzees.
• The chimpanzee version of HIV is called simian immunodeficiency virus (SIV).
• The virus likely transferred to humans who hunted chimpanzees for meat and came into contact with infected blood.
• The mutated version spreads from human to human.

AIDS Defined

• AIDS, or acquired immune deficiency syndrome, describes potentially life-threatening infections and illnesses.
• AIDS occurs when the immune system is severely damaged by HIV.

Stages of HIV

Stage 1: Seroconversion Illness

• This stage involves a short illness after contracting HIV, lasting up to 6 weeks.
• Seroconversion illness can be referred to as the primary or acute HIV infection.
• It may be asymptomatic or present like the flu.
• Individuals are most infectious during seroconversion.

Stage 2: Asymptomatic Stage

• Most people feel fine and experience no symptoms once seroconversion ends.
• This stage can last for several years.
• The virus remains active, infecting cells, making copies, and weakening the immune system.

Stage 3: Symptomatic HIV

• The risk of infections and cancers increases without treatment.
• The weakened immune system struggles to fight these conditions.
• Being ill due to opportunistic infections means a person has symptomatic HIV.

Stage 4: Late-Stage HIV

• Late-stage HIV involves serious opportunistic infections and cancers.
• These illnesses are known as AIDS-defining conditions.

AIDS-Defining Illnesses Examples

• Candidiasis of the esophagus, bronchi, trachea, or lungs (but not oral)
• Invasive cervical cancer
• Coccidioidomycosis, disseminated or extrapulmonary
• Cryptococcosis, extrapulmonary
• Chronic intestinal cryptosporidiosis (lasting >1 month)
• Cytomegalovirus disease or CMV (excluding liver, spleen, or nodes)
• Cytomegalovirus retinitis with vision loss
• HIV-related encephalopathy
• Chronic herpes simplex ulcers or bronchitis, pneumonitis, or esophagitis (lasting >1 month)
• Disseminated or extrapulmonary histoplasmosis
• Chronic intestinal isosporiasis (lasting >1 month)
• Kaposi sarcoma
• Burkitt's lymphoma (or equivalent)
• Immunoblastic lymphoma (or equivalent)
• Primary lymphoma of the brain
• Disseminated or extrapulmonary Mycobacterium avium complex or M kansasii
• Mycobacterium tuberculosis at any site
• Disseminated or extrapulmonary Mycobacterium (other or unidentified species)
• Pneumocystis pneumonia (PCP)
• Recurrent pneumonia
• Progressive multifocal leukoencephalopathy
• Recurrent Salmonella septicemia
• Toxoplasmosis of the brain
• Wasting syndrome due to HIV

Common AIDS-Defining Illnesses

Non-Hodgkin Lymphoma

• Non-Hodgkin lymphoma is a cancer of the lymphatic system.
• Its most common symptom is painless swelling in a lymph node, typically in the neck, armpit, or groin.

Lymphatic System

• The lymphatic system supports the body's immune function, helping protect against infection and disease.
• Its components include lymph vessels, lymph nodes, lymphocytes, lymphatic organs, and lymphatic tissue.

Tuberculosis (TB)

• TB is caused by the bacterium Mycobacterium tuberculosis.
• HIV increases the risk of TB infection.
• Coinfection refers to infection with both HIV and TB.
• People living with HIV (PLHIV) are 19 times more likely to develop TB.

Cryptococcal Meningitis

• Cryptococcal meningitis is caused by the fungus Cryptococcus neoformans.
• Microscopic fungus, breathed in by most people, rarely causes sickness.
• Cryptococcus can stay hidden in the body and later cause cryptococcal meningitis, serious but not contagious brain infection, particularly in people with HIV.

Cachexia

• Cachexia, or wasting syndrome/anorexia cachexia syndrome, is not limited to HIV.
• It is a complex process of sudden loss of mass (weight)

Kaposi's Sarcoma (KS)

• Herpes virus type 8 (HHV-8) causes Kaposi’s sarcoma (KS).
• HHV-8 is common; most people with it do not develop Kaposi's sarcoma.
• The virus spreads through sex, blood, saliva, or perinatal transmission.
• It can cause cancer in those with weakened immune systems or genetic vulnerabilities.
• A weakened immune system allows the HHV-8 virus to multiply.
• The virus alters genetic instructions for cell growth, causing uncontrolled reproduction of endothelial cells, forming tumors.
• It primarily affects endothelial cells lining blood and lymphatic vessels.
• Kaposi's sarcoma be limited to the skin or involve lymph nodes and internal organs.

Candidiasis

• Candidiasis is a fungal infection caused by yeast called Candida.
• It typically affects the bronchi, trachea, lungs, or esophagus.
• Oropharyngeal candidiasis is a common opportunistic infection in individuals with HIV.
• The infection presents as easily removable, curd-like white plaques over raw or bleeding mucosa.
• Predominant symptoms includes a sore mouth and throat.
• Patients with esophageal candidiasis have dysphagia and/or odynophagia.
• Respiratory symptoms include increased phlegm, chronic cough, and hoarseness.

Hairy Leukoplakia

• Oral hairy leukoplakia is triggered by the Epstein-Barr virus.
• It occurs mainly in immunocompromised people like people with HIV.
• Hairy leukoplakia is a warning sign of HIV or a weakened immune system.
• It causes white patches on the tongue, which may cause mild discomfort and taste changes.
• Treatment focuses on the underlying immune issue, such as HIV.

Mental Health

• Those living with HIV/AIDS (PLWHA) face higher rates of modifiable cancer risks.
• Modifiable cancer risks are things that can often be avoided with lifestyle changes like smoking, drinking alcohol, and infection with HPV and hepatitis B and C.
• 54% of HIV positive people included in the study were smokers – around two-and-a-half times higher than the general American population
• 5% of HIV positive people were co-infected with hepatitis B compared to 0.3% of the general population with hepatitis B.
• 26% of the individuals had chronic hepatitis C compared to 0.9% of the general American population.
• 46% of women had HPV infection that could lead to cancer compared to 29% of the general US population.
• 68% of men who have sex with men had anal HPV infection with a risk of leading to cancer, although there were no general population figures available.
• Guidelines state consuming more than 14 units of alcohol each week increases risks of cancer. Increased death rate in HIV+ men who drink more than 13 units of alcohol has been found

Transmission of HIV

• HIV is found in semen, vaginal/anal fluids, blood, and breast milk.
• The most common way of getting HIV in the UK is through having anal or vaginal sex without a condom.
• Anal sex carries the highest risk, especially for the passive partner.
• The chance of getting HIV through oral sex is very low.
• HIV cannot be transmitted through sweat, urine, or saliva.

HIV Risk Factors

• Risk factors of contracting HIV include sexually transmitted infections (STIs), sharing contaminated needles/syringes, unsafe injections/transfusions/transplants, or needle stick injuries.

Diagnosing HIV

• Seek medical advice asap if you think you might have been exposed to HIV.
• If you experience a needle stick, contact occupational health services immediately.
• If the patient is known to have HIV, ask if they would be happy to attend occupational health for blood tests.
• Ask for the patients viral load if they know it
• The only way to find out if you have HIV is to have an HIV test.

Coming into Contact with HIV

• Awareness of PEP needed within 72 hours.
• Negative HIV tests may need repeating at 6, 12, and 24 weeks post-incident.
• Positive tests lead to referral to a specialist HIV clinic for further testing and treatment discussion.

Treatment for HIV

• Antiretroviral medicines (ART) is used to treat HIV.
• ART works by stopping the virus replicating in the body.
• Combination of different medicines taken every day
• The goal of HIV treatment is to have an undetectable viral load.
• Viral load measures the amount of HIV in the blood.
• A test measures how much virus is in the body.
• Measured in copies of HIV per milliliter of blood.
  • U=U - 200 copies/ml.
  • Low - 10,000 copies/ml.
  • High – >100,000 copies/ml.

HIV Prevention

Pre-Exposure Prophylaxis (PrEP)

• Blocks the acquisition of HIV.
• It is prevention choice
• Taken regularly (one tablet per day) or 2+1+1 dosing.
• Use Truvada

Post-Exposure Prophylaxis (PEP)

• Started within 72 hours of exposure.
• It is a 28-day course of ARV drugs.
• WHO recommends use for occupational and non-occupational exposures for adults and children.
• Consists of Truvada and raltegravir.

Ending the Stigma

• There were around 105,200 people living with HIV in the UK in 2019.
• 94% of these people are diagnosed and therefore 6% do not know.
• Around 1 in 16 people living with HIV in the UK do not know that they have the virus.
• 98% of people diagnosed with HIV/AIDS in the UK are on treatment and 97% of whom are virally suppressed which means they can't pass the virus on.
• 69.1% of people are male, and 30.9% are female
• The mode of transmission is
• Heterosexual contact (46.1%), Sex between men (46.4%), injecting drug use (1.9%) and unknown (2.7%)
• 91.5% live in England, 5% scotland and 1.1% Northern Ireland

Considerations in the Surgery

• Do not book at the end of the day, place used items in a separate bag, double glove, refuse to see the patient, ridicule or be derogatory about the patient, or make assumptions
• Do use universal precautions, have a welcoming attitude, treat the patient with dignity and carry out treatment the same as a non-HIV patient.
• Advice given include taking rest, ensuring a optimal and balanced diet, stop smoking, yearly flu prevention jabs, reduce alcohol intake, and ensue optimal oral hygiene