HIV / AIDS
Kolářová M., EPI
Spring 2018
ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
AND HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION - case definition
Clinical Criteria (AIDS)
• Any person who has any of the clinical conditions as
defined in the European AIDS case definition for:
• — Adults and adolescents ≥ 15 years
• — Children < 15 years of age
Laboratory Criteria (HIV)
Adults, adolescents and children aged ≥ 18 months
At least one of the following three:
• — Positive result of a HIV screening antibody test or
a combined screening test (HIV antibody and HIV
p24 antigen) confirmed by a more specific antibody
test (e.g. Western blot)
• — Positive result of 2 EIA antibody test confirmed
by a positive result of a further EIA test
• — Positive results on two separate specimens from
at least one of the following three:
• — Detection of HIV nucleic acid (HIV-RNA, HIV-
DNA)
• — Demonstration of HIV by HIV p24 antigen test,
including neutralisation assay
• Isolation of HIV
Children aged < 18 months
• Positive results on two separate specimens (excluding
cord blood) from at least one of the following three:
• — Isolation of HIV
• — Detection of HIV nucleic acid (HIV-RNA, HIV-DNA)
• — Demonstration of HIV by HIV p24 antigen test,
including neutralisation assay in a child ≥ 1 month of
age
Epidemiological Criteria: NA
Case Classification
• A. Possible case NA
• B. Probable case NA
• C. Confirmed case
• — HIV infection
• Any person meeting the laboratory criteria for HIV
infection
• — AIDS
• Any person meeting the clinical criteria for AIDS and
the laboratory criteria for HIV infection
HIV disease continues to be a serious health issue for parts of the world.
Worldwide, there were about 2.1 million new cases of HIV in 2015.
About 36.7 million people are living with HIV around the world,
and as of June 2016, 17 million people living with HIV were
receiving medicines to treat HIV, called antiretroviral therapy (ART).
An estimated 1.1 million people died from AIDS-related illnesses in 2015.
Sub-Saharan Africa, which bears the heaviest burden of HIV/AIDS
worldwide, accounts for 65% of all new HIV infections.
Other regions significantly affected by HIV/AIDS include Asia and
the Pacific, Latin America and the Caribbean, and Eastern Europe
and Central Asia.
Fosfolipid membrane
gp120 surface glykoprotein
gp 41 transmembrane
glykoprotein
p 17M protein - matrix
p 24 protein – nucleocapsid core
RNA genome
reverzní transkriptáza
p 7, p 9
proteiny on the nucleic acide
HIV/AIDS
HIV - Human Immunodeficiency Virus is classed with the
Retroviridae family, Lentivirus genus. HIV occurs in two types:
HIV - 1 and HIV - 2. Both types have similar epidemiological
features, but different serological response and geographic
distribution. .
Only infected people are the sources of infection, in either the sick with manifestations
of AIDS or a latent infection, (ARC - AIDS-Related Complex, PGL - Persistent
Generalised Lymphadenopathy) or a symptomless carrier.
Blood - borne By blood derivates and HIV- contaminated blood.
Use of contaminated needles and syringes in drug administration.
Sexually-transmitted, when injury of the mucosa and bleeding occur.
Sexually transmitted Through sperma, vaginal secrets in homo and heterosexual
intercourse.
From mother to child (15 to 30 %) Vertical transmission - prenatally, perinatally or
possibly through the mother´s milk.
General.
General
The source of
infection
Route of
transmission
Susceptibility
Etiology:
Preventive measures:
Health education promoting a responsible approach to sex - use of condoms.
To prevent contamination of blood tins and derivates.
Supporting the programme of taking/giving needles and syringes from/to intravenous drug addicts.
Virus classification
Group: Group VI (ssRNART)
Family: Retroviridae
Genus: Lentivirus
Species:Human immunodeficiency virus1
Species:Human immunodeficiency virus 2
Diagram of HIV is different in structure from other
retroviruses.
It is about 120 nm in diameter (120 billionths of a
meter; around 60 times smaller than a red blood
cell) and roughly spherical.
HIV primarily infects vital cells in the human immune
system such as helper T cells (specifically CD4+ T cells),
macrophages and dendritic cells.
HIV infection leads to low levels of CD4+ T cells through
three main mechanisms:
•firstly, direct viral killing of infected cells;
•secondly, increased rates of apoptosis in infected cells;
•and thirdly, killing of infected CD4+ T cells by CD8
cytotoxic lymphocytes that recognize infected cells.
When CD4+ T cell numbers decline below a critical level,
cell-mediated immunity is lost, and the body becomes
progressively more susceptible to opportunistic infections.
The AIDS epidemic was discovered June 5, 1981, when
the U.S. Centers for Disease Control and Prevention (CDC)
reported a cluster of Pneumocystis carinii pneumonia (now
classified as Pneumocystis jiroveci pneumonia) in five
homosexual men in Los Angeles.
The disease was originally dubbed GRID, or Gay-Related
Immune Deficiency, but health authorities soon realized
that nearly half of the people identified with the syndrome
were not homosexual men.
In 1982, the CDC introduced the term AIDS to describe the
newly recognized syndrome, though it was still casually
referred to as GRID.
In 1983, scientists led by Luc Montagnier at the Pasteur
Institute in France first discovered the virus that causes
AIDS. They called it lymphadenopathy-associated virus
(LAV).
A year later a team led by Robert Gallo of the United States
confirmed the discovery of the virus, but they renamed it
human T lymphotropic virus type III (HTLV-III).
The dual discovery led to considerable scientific
disagreement, and it was not until President Mitterrand of
France and President Reagan of the USA met that the
major issues were resolved.
In 1986, both the French and the U.S. names for the virus
itself were dropped in favour of the new term, human
immunodeficiency virus (HIV).
AIDS – Acquired ImmunoDeficiency Syndrome
SIDA – Syndrome d´ImmunoDeficience Acquise
SPID – Syndrom Priobretěnovo ImunoDeficita
HIV - Human Immunodeficiency Virus
• Three of the earliest known instances of HIV-1
infection are as follows:
• A plasma sample taken in 1959 from an adult male
living in what is now the Democratic Republic of
Congo.
• HIV found in tissue samples from a 15-year-old
African-American teenager who died in St. Louis in
1969.
• HIV found in tissue samples from a Norwegian
sailor who died around 1976.
• Although a variety of theories exist explaining the transfer of HIV
to humans, no single hypothesis is unanimously accepted, and the
topic remains controversial.
• The most widely accepted theory is so called 'Hunter' Theory
according to which transference from chimp to human most likely
occurred when a human was bitten by a chimp or was cut while
butchering one, and the human became infected.
.
Subtypes:
HIV 1 - group“M” (major) – subtypes A, B, C, D, E, F, G, H, I,…
(expected other)
Subtypes:
A – West and Middle Africa
B – Europe, North and sud America, Thailand
C – Sud Africa, Indie
D – Middle Africa
E – Middle Africa, Thailand, Indie
F – Brazilie, Romania, Zair
G – Middle Africa
H – Gabun, Zair
I – Africa
Antiretroviral treatment reduces both the mortality
and the morbidity of HIV infection, but routine access
to antiretroviral medication is not available in all
countries.
If untreated, eventually most HIV-infected individuals
develop AIDS (Acquired Immunodeficiency
Syndrome) and die; however about one in ten
remain healthy for many years, with no noticeable
symptoms.
• Since the beginning of the pandemic, three main
transmission routes for HIV have been identified:
• Sexual route. The majority of HIV infections are acquired
through unprotected sexual relations. Sexual transmission
can occur when infected sexual secretions of one partner
come into contact with the rectal, genital or oral mucous
membranes of another.
Blood or blood product route. This transmission route
can account for infections in intravenous drug
users, hemophiliacs and recipients of blood
transfusions (though most transfusions are checked
for HIV in the developed world) and blood products.
It is also of concern for persons receiving medical
care in regions where there is prevalent
substandard hygiene in the use of injection
equipment, such as the reuse of needles in Third
World countries. HIV can also be spread through
the sharing of leaches.
Health care workers such as nurses, laboratory
workers, and doctors, have also been infected,
although this occurs more rarely.
People who give and receive tattoos, piercings and
scarification procedures can also be at risk of
infection.
Mother-to-child transmission (MTCT). The transmission of
the virus from the mother to the child can occur in utero
during the last weeks of pregnancy and at childbirth. In
the absence of treatment, the transmission rate between
the mother and child is 25%. However, where drug
treatment and Cesarian section are available, this can be
reduced to 1%. Breast feeding also presents a risk of
infection for the baby.
• HIV-2 is transmitted much less frequently by the MTCT
and sexual route than HIV-1.
HIV has been found at low concentrations in the:
saliva,
tears and
urine of infected individuals,
but there are no recorded cases of infection by
these secretions and the potential risk of
transmission is negligible.
The use of physical barriers such as the latex
condom is widely advocated to reduce the sexual
transmission of HIV.
Spermicide, when used alone or with vaginal
contraceptives like a diaphragm, actually increases
the male to female transmission rate due to
inflammation of the vagina;
it should not be considered a barrier to infection.
HIV does not survive long outside the human body (such as on
surfaces), and it cannot reproduce outside a human host.
It is not spread by:
• Mosquitoes, ticks, or other insects.
• Saliva, tears, or sweat that is not mixed with the blood of an
HIV-positive person.
• Hugging, shaking hands, sharing toilets, sharing dishes, or
closed-mouth or “social” kissing with someone who is HIV-
positive.
• Other sexual activities that don’t involve the exchange of
body fluids (for example, touching).
• The chance that an HIV-negative person will get HIV from
oral sex with an HIV-positive partner is extremely low.
• Oral sex involves putting the mouth on the penis (fellatio), vagina
(cunnilingus), or anus (anilingus). In general, there’s little to no
risk of getting or transmitting HIV through oral sex.
• Factors that may increase the risk of transmitting HIV through oral
sex are ejaculation in the mouth with oral ulcers, bleeding gums,
genital sores, and the presence of other sexually transmitted
diseases (STDs), which may or may not be visible.
• You can get other STDs from oral sex. And, if you get feces in
your mouth during anilingus, you can get hepatitis A and B,
parasites like Giardia, and bacteria like Shigella, Salmonella,
Campylobacter, and E. coli.
The risk of health care workers being exposed to HIV on the
job (occupational exposure) is very low, especially if they use
protective practices and personal protective equipment to
prevent HIV and other blood-borne infections. For health care
workers on the job, the main risk of HIV transmission is from
being stuck with an HIV-contaminated needle or other sharp
object. However, even this risk is small. Scientists estimate
that the risk of HIV infection from being stuck with a needle
used on an HIV-infected person is less than 1%.
Kaposi's sarcoma in a 20-year old man who had AIDS.
• Postexpoziční profylaxe (PEP) HIV po pohlavním styku není v ČR hrazena z veřejných
zdrojů. Preexpoziční profylaxe (PrEP) není v ČR zatím součástí doporučeného postupu
vůbec. Přitom mezinárodní organizace a asociace obě modality jednoznačně doporučují
jako součást preventivních strategií zejména mezi MSM. PrEP prokázala vysokou účinnost v
prevenci HIV sérokonverze u MSM, je dobře tolerována, vznik rezistence je nízký a
(kompenzační) nárůst rizikového sexuálního se nekoná [Spinner a kol., 2016]. Jako
standardní metoda byla PrEP v roce 2016 zavedena ve Francii, Norsku a prakticky ve Velké
Británii, v 17 dalších evropských zemích proběhly, probíhají nebo se chystají tzv. PrEP
demonstrační projekty; ČR však mezi nimi chybí [European Centre for Disease Prevention
and Control, 2016, out.com, 2016, NHS England, 2016]. I když je PrEP aktuálně dávána do
souvislosti se zvýšeným rizikem dalších STI vlivem nárůstu podílu sexuálních styků bez
kondomu a zvýšení počtu sexuálních partnerů, je pravděpodobné, že se na něm podílí
rovněž zvýšená protestovanost nebo selekční bias, protože ve studiích PrEP se pravidelně
vyšetřují i další STI a jsou do nich cíleně zařazovány právě osoby s vysokou mírou
rizikového chování již při vstupu do studie. V souvislosti s jinými STI je PrEP vnímána jako
příležitost ke zlepšení jejich včasné diagnostiky a léčby mezi MSM s nejvyšší mírou
rizikového chování [Kojima a kol., 2016, Scott a Klausner, 2016].
New“ strategy under N. Ramjee, 2006
A, B, C, D, E, F, G, H, (I)
A – abstinence
B – be faithful – být si vzájemně věrný, buď věrný
C – kondom (mužský kondom)
C = také femidom neboli kondom
D – diafragma (poševní) with spermicid
D – dental dam – dentální rouška
E – exposure prophylaxis
F – female initiated microbicides
G – genital tract infections – therapy
H – HSV 2 suppression Herpes simplex 2
I – „imunity induced by vaccine“ ?????
Pre-exposure prophylaxis or PrEP
is the use of an antiretroviral medication to prevent the acquisition
of HIV infection by uninfected persons.
PrEP may either be taken orally, using an antiretroviral drug
available for treatment of HIV infection (tenofovir plus
emtricitabine), or topically as a vaginal gel containing tenofovir.
The efficacy of oral PrEP has been shown in four randomized control trials and is high when
the drug is used as directed.
The efficacy of gel has been shown in one trial and is moderate.
As of September 2015, WHO recommends that people at
substantial risk of HIV infection should be offered PrEP as an
additional prevention choice, as part of comprehensive prevention.
30
Conclusions (1)
•HIV infection is of major public health importance in Europe, with
evidence of continuing transmission in specific populations with no
clear signs of overall decrease.
•Half of the HIV infections were diagnosed as late presenters with CD4
cell counts less than 350/mm3 blood.
•Heterogeneity exists in HIV epidemics in the EU/EEA:
 Men who have sex with men accounted for majority of cases;
 One third of heterosexual cases have direct links to subSaharan
Africa (areas with a generalised epidemic);
 Despite low levels of HIV reported in IDU, increases continue
in Greece and Romania.
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
Conclusions (2)
•Interventions should be based on evidence and tailored to the
local epidemiological situation and vulnerable populations such
as MSM, IDU and migrant populations.
•Wider access and uptake of HIV counselling and testing is
needed to ensure earlier diagnosis and access to treatment –
both to improve the longer term treatment outcomes for the
individuals but also to prevent or reduce further transmission in
the community.
31Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
Vertical transmission -CDC
HIV and AIDS Diagnoses
Approximately 8,500 women living with HIV give birth annually.
Most (73%) of the estimated 174 children in the United States who were diagnosed with
HIV in 2014 got HIV through perinatal transmission.
Most (88%) of the estimated 104 children in the United States diagnosed with AIDS in 2014
got HIV through perinatal transmission.
Living With HIV
Of the estimated 1,999 children living with perinatal HIV at the end of 2013, 1,298 (65%)
were black/African American, 312 (16%) were Hispanic/Latino,b and 212 (11%) were white.
At the end of 2013, an estimated 9,131 adults and adolescents (aged 13 and older) were
living with HIV acquired through perinatal transmission. Of these, 60% (5,495) were
black/African American, 23% (2,093) were Hispanic/Latino, and 12% (1,118) were white.
Deaths
An estimated 4,998 children ever diagnosed with AIDS have died since the beginning of
the epidemic through the end of 2013 (includes only those under age 13 at time of death).c
Almost all of them (91%) got HIV through perinatal transmission.
Summary of global HIV epidemic (2016)
People living with HIV by WHO region (2016)
36.7 million [30.8 million – 42.9 million]
34.5 million [28.8 million – 40.2 million]
17.8 million [15.4 million – 20.3 million]
16.7 million [14.0 million – 19.5 million]
2.1 million [1.7 million – 2.6 million]
1.8 million [1.6 million – 2.1 million]
1.7 million [1.4 million – 1.9 million]
160 000 [100 000 – 220 000]
1.0 million [830 000 – 1.2 million]
890 000 [740 000 – 1.1 million]
120 000 [79 000 – 160 000]
Number of people living
with HIV in 2016
People newly infected
with HIV in 2016
AIDS deaths in 2016
Total
Adults
Women
Men
Children (<15 years)
Total
Adults
Children (<15 years)
Total
Adults
Children (<15 years)
Source: UNAIDS/WHO estimates.
Summary of global HIV epidemic (2016)
Source: UNAIDS/WHO estimates.
0
500 000
1 000 000
1 500 000
2 000 000
2 500 000
3 000 000
3 500 000
4 000 000
1990 1991 1992 1993 1994 1995 1996 1997 1998 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
People newly infected with HIV
globally
Decline in HIV incidence and mortality over time
19% 40% 90%
Number of people newly infected with HIV
UNAIDS/WHO estimates
Future
targets
19% 40% 90%
Number of people dying from HIV
Future
targets
UNAIDS/WHO estimates
19% 40% 90%
Number of people receiving
antiretroviral treatment
Future
targets
UNAIDS/WHO estimates
Mid-2017 20.9
million
2015
HIV/AIDS surveillance in Europe
European Centre for Disease Prevention and Control, Stockholm
WHO Regional Office for Europe, Copenhagen
Among the 49 reporting countries3 the rate was
7.6 per 100 000 population
and 6.3 per 100 000 for the EU/EEA
Cumulative number of new diagnosis in the EU/EEA and other
countries of the WHO European Region
AIDS diagnoses reported per 100 000 population 2015
HIV infections diagnosed, 2012
48
Characteristics of reported cases EU/EEA
Number of HIV diagnoses 29 381
Diagnoses per 100 000 population 5.8
Percentage aged 15–24 years 10.6%
Male-to-female ratio 3.2
Transmission mode (percentage)
Heterosexual 33.8%*
Men who have sex with men 40.4%
Injecting drug use 6.1%
Unknown 18.7%Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
HIV infections diagnosed and reported, 2012
Injecting drug use, EU/EEA
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
50
HIV diagnoses in persons originating from countries with a
generalised epidemic among all the heterosexually acquired
infections, 2012 (n=9 944)
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
HIV diagnoses in MSM among all reported HIV cases, by
country, EU/EEA, 2012 (n=29 381)
51Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
Male-to-female ratio of HIV infections, by country,
EU/EEA, 2012 (n=29 327)
52Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
Rate of reported HIV diagnoses, by year of diagnosis,
in the EU/EEA, 1984–2012
53Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
HIV infections reported, 2006-2012
Transmissionmodeand origin,adjusted forreportingdelay
54
Predominant transmission mode: men who have sex with men
Data were not included or not available from Estonia, Poland, Spain, Italy.
Source: ECDC/WHO. HIV/AIDS Surveillance in Europe, 2012
Celkový stav vyšetřování
HIV protilátek v ČR
Kumulativní údaje k 31.1.2018
Trend zachován i přes zdánlivý pokles
2017 = 232 mužů – prům. věk 17 – 65 let
+ 22 žen prům. věk 13 – 59 let
Mimo ČR
Z toho 5 rezidentky.
Celkem narozeno 13 dětí od HIV + matek (8 věděly + 5 zjištěno při skríningu