1

HIV & AIDS ARE DIFFERENT ENTITIES

Receptor Nucleus DNA

HIV/AIDS Worldwide
38 million people live with
HIV/AIDS worldwide.

Sub-Saharan Africa is home to 70% of the people living

with HIV.

2.1 million children are infected

with HIV/AIDS in the world

Top HIV/AIDS-Infected Countries

1. 2. 3.

South Africa Nigeria Zimbabwe Tanzania The Congo Ethiopia Kenya Mozambique

9. 10.

United States Russian Federation

11.China 12. 13. Brazil Thailand

SubSaharan Africa

4. 5. 6. 7. 8.

Source: Steinbrook R. The AIDS epidemic in 2004. NEJM. 2004;351:115-117.

The U.S. Epidemic: Snapshot of Key Data

New infections each year People living with HIV/AIDS People with HIV/AIDS not in care People with HIV who dont know theyre infected 40,000 1,039,000 1,185,000 42 59%

Figure 1

24 27%

Note: Data are estimates. Sources: CDC, 2005; Glynn, K. et al., CDC, "Estimated HIV prevalence in the United States at the end of 2003", Presentation at the National HIV Prevention Conference, 2005; Fleming, P., et al., HIV Prevalence in the United States 2000, 9th Conference on Retroviruses and Opportunistic Infections, 2002.

Perjalanan Klinis Infeksi HIV.

TERINFEKSI
2-3 mgg

Acute Retroviral Syndrome

2-3 mgg

Sembuh Seroconvesion
AIDS
8 THN

1,3 TH

ASIMTOMATIK

IS THERE A CURE? There is NO cure for HIV/AIDS

Figure 20

HIV Prevention

HIV Prevention Funding at CDC, FY 1995-2005 (US $ Millions)

Centers for Disease Control and Prevention (CDC)

1 1
Medicare 1 Ryan White

$589.8
All Other 51% ($6.0B)

$616.8 $656.6

Most prevention funding Funds go to states; some cities; community based organizations; other entities/programs
Additional prevention funding also at: Department of Veterans Affairs, SAMHSA, and other agencies National HIV prevention goal (reduce new infections by 50% by 2005) was not met

2 2 2

$749.7 $793.6 $731.7

Sources: CDC, Personal Communication, 2006; CDC, HIV Prevention Strategic Plan Through 2005.

Pertama Kali Timbul di Afrika, Haiti dan USA 1978 1979 Sarkoma Kaposi pada orang Afrika yang mukim di Eropa 1981 USA . Sarkoma Kaposi di kalangan Homo Seks 1982 Luc Montagnier ,Paris. LAV (Limphadenonathy Associated Virus) 1984 Transmisi Heteroseks, Galo dkk. HTLV IIII 1986 Penyebab AIDS adalah HIV

 Indonesia : Kasus pertama ( BALI ) :April 1987. Wisatawan Belanda Kasus kedua ( Jakarta ) :Nopember 1987. Warga Kanada tinggal di JKT. Kasus ketiga ( Jakarta ) : 1989. Warga Perancis tinggal di JKT Orang Indonesia Pertama di Bali: Juni 1988

Characteristics of the virus

HIV
The outer shell of the virus is known as the Viral enevlope. Embedded in the viral envelope is a complex protein known as env which consists of an outer protruding cap glycoprotein (gp) 120, and a stem gp14. Within the viral envelope is an HIV protein called p17(matrix), and within this is the viral core or capsid, which is made of another viral protein p24(core antigen).

13

14

Life Cycle
(a) HIV (red) attaches to two cell-surface receptors (the CD4 antigen and a specific chemokine receptor). (b) The virus and cell membrane fuse, and the virion core enters the cell. (c) The viral RNA and core proteins are released from the virion core and are then actively transported to the nucleus. (d) The viral RNA genome is converted into doublestranded DNA through an enzyme unique to viruses, reverse transcriptase (red dot). (e) The double-stranded viral DNA moves into the cell nucleus. (f) Using a unique viral enzyme called integrase, the viral DNA is integrated into the cellular DNA. (g) Viral RNA is synthesized by the cellular enzyme RNA polymerase II using integrated viral DNA as a template. Two types of RNA transcripts shorter spliced RNA (h) and full-length genomic RNA (j) are produced. (h) Shorter spliced RNAs are transported to the cytoplasm and used for the production of several viral proteins that are then modified in the Golgi apparatus of the cell (i). (j) Full-length genomic RNAs are transported to the cytoplasm (k). (l) New virion is assembled and then buds off. (m) Mature virus is released.

Viral Replication
First step, HIV attaches to susceptible host cell.
Site of attachment is the CD4 antigen found on a variety of cells
helper T cells macrophages monocytes B cells microglial brain cells intestinal cells

T cells infected later on.

Early Phase HIV Infection

In early phase HIV infection, initial viruses are M-tropic. Their envelope glycoprotein gp120 is able to bind to CD4 molecules and chemokine receptors called CCR5 found on macrophages

http://www.cat.cc.md.us/courses/bio141/lecguide/unit2/viruses/hivad.html

In late phase HIV infection, most of the viruses are T-tropic, having gp120 capable of binding to CD4 and CXCR4 found on T4lymphocytes.

Early Phases of HIV Infection of Mucosal Surfaces

Cell free

HIV

T-cell Immature Dendritic cell Skin or mucosa 24 hours 1. HIV co-receptors, CD4 + chemokine receptor CC5 2. Selective of macrophagetropic HIV Via lymphatics or circulation 48 hours 3. Mature Dendritic cell in regional LN undergoes a single replication, which transfers HIV to T-cell

PEP
Burst of HIV replication

19

HIV (arrows) Infecting a T-lymphocyte

HIV

Human Immunodeficiency Virus

Virus penyebab AIDS Melemahkan sistem kekebalan tubuh (sel darah putih)

AIDS

Acquired Immune Deficiency Syndrome

Kumpulan beberapa gejala akibat menurunnya sistem kekebalan tubuh yang disebabkan oleh HIV.

CD4 Count in HIV infection

The CD4 cell , also known as "T4" or "helper T cell is responsible for signaling other parts of the immune system to respond to an infection. Normal counts range from 500 to 1500 cells per cubic millimeter of blood Initially in HIV infection there is a sharp drop in the CD4 count and then the count levels off to around 500-600 cells/mm3. CD4 count is a marker of likely disease progression. CD4 percentage tends to decline as HIV disease progresses. CD4 counts can also be used to predict the risks for particular conditions such as Pneumocystis carinii pneumonia, CMV disease or MAI disease. Treatment decisions are often based on Viral Load and CD4 count.

 Siapapun bisa tertular HIV, jika perilakunya berisiko. Penampilan luar bukan jaminan bebas HIV. Orang dengan (+)HIV sering terlihat sehat dan merasa sehat. Jika belum melakukan tes HIV, orang dengan (+)HIV tidak tahu bahwa dirinya sudah tertular HIV dan dapat menularkan HIV pada orang lain. Tes HIV adalah satu-satunya cara untuk mendapatkan kepastian tertular HIV atau tidak.

Tertular HIV

Periode Jendela*

HIV Positif

AIDS

2 minggu - 6 bulan

3 - 10 Tahun

1 - 2 Tahun
Timbul infeksi oportunistik

* Masa antara masuknya HIV Tanpa Gejala kedalam tubuh manusia Tampak sehat sampai terbentuknya antibody Dapat beraktiterhadap (+)HIV. vitas biasa. Sudah bisa menularkan HIV kepada orang lain.

typical primary HIV-1 infection

symptoms symptoms

HIV proviral DNA HIV antibodies window period

HIV viral load

HIV-1 p24 antigen

0 1 1 infection 2 3
weeks

6
years

10

Time following infection

Natural History of Untreated HIV Infection

Four Stages of HIV

Stage 1 - Primary
Short, flu-like illness - occurs one to six weeks after infection no symptoms at all

Infected person can infect other people

Stage 2 - Asymptomatic
Lasts for an average of ten years
This stage is free from symptoms There may be swollen glands The level of HIV in the blood drops to very low levels

HIV antibodies are detectable in the blood

Stage 3 - Symptomatic
The symptoms are mild The immune system deteriorates

emergence of opportunistic infections and cancers

Stage 4 - HIV AIDS

The immune system weakens The illnesses become more severe leading to an AIDS diagnosis

Opportunistic Infections associated with AIDS

Bacterial
Tuberculosis (TB) Strep pneumonia

Viral
Kaposi Sarcoma Herpes Influenza (flu)

Opportunistic Infections associated with AIDS

Parasitic
Pneumocystis carinii

Fungal
Candida Cryptococcus

AIDS
CD4 count drops below 200 person is considered to have advanced HIV disease If preventative medications not started the HIV infected person is now at risk for:
Pneumocystis carinii pneumonia (PCP) cryptococcal meningitis toxoplasmosis

If CD4 count drops below 50:

Mycobacterium avium Cytomegalovirus infections lymphoma dementia Most deaths occur with CD4 counts below 50.

HIV menular melalui :

Menggunakan jarum suntik : secara bergantian bekas pakai tidak steril Hubungan seks berganti-gantian pasangan Dari ibu ke bayi melalui : Hamil Melahirkan menyusui

Modes of HIV/AIDS Transmission

Transmission

Through Bodily Fluids

Blood products Semen Vaginal fluids Breast Milk

Penularan AIDS dapat melalui:

Hubungan seksual yang memungkinkan pemindahan virus dari sperma dan cairan vagina/ serviks

Pemindahan darah yang mengandung HIV Penularan kepada janin dari ibu penderita AIDS

Kelompok Resiko Tinggi

1. Aktif dalam perilaku seksualnya( WTS, PTS )
2. Homoseksual. 3. Mereka yg suka/ pernah melakukan hubungan seksual dgn orang asing yang berasal dari daerah dimana insidens AIDS tinggi. 4. Penyalah guna obat/narkotika

Through Sex
Intercourse (penile penetration into the vagina) Oral Anal Digital Sex

Mother-to-Baby
Before Birth During Birth Postpartum
After the birth

Oral Candidiasis (thrush)

Oral Hairy Leukoplakia

Being that HIV reduces immunologic activity, the intraoral environment is a prime target for chronic secondary infections and inflammatory processes, including OHL, which is due to the Epstein-Barr virus under immunosuppressed conditions

Kaposis sarcoma (KS)

Kaposis sarcoma (shown) is a rare cancer of the blood vessels that is associated with HIV. It manifests as bluish-red oval-shaped patches that may eventually become thickened. Lesions may appear singly or in clusters.

HIV tidak menular melalui :

Gigitan nyamuk atau serangga lain Berenang bersama Memakai toilet umum Bersalaman, pelukan ataupun ciuman Terpapar batuk atau bersin Berbagi makanan atau menggunakan alat makan bersama Air kotor, Udara

Bagaimana mengetahui status HIV ?

Status HIV hanya dapat diketahui melalui Konseling dan Testing HIV Sukarela Testing HIV merupakan pengambilan darah dan pemeriksaan laboratium disertai konseling pre dan pasca testing HIV Konseling dan Testing HIV Sukarela dilakukan dengan prinsip tanpa paksaan, rahasia, tidak membeda-bedakan serta terjamin kualitasnya.

Cara Mencegah Penularan HIV :

Anda tidak melakukan seks bukan dgn pasangannya Bersikap saling setia dengan pasangan Cegah dengan memakai kondom lateks Jangan menggunakan narkoba suntik

Beberapa Aturan Pokok Keperawatan

Perawat disarankan memakai baju penutup dan sarung tangan bila memegang tubuh penderita, khususnya bila ada kemungkinan terkena sekret tubuhnya. Memberi makan, sama seperti pada penderita Hepatitis B. Beri pelindung pada jasur dan bantal ( plastik ) Sprei, perlu diketahui bahwa HIV sgt mudah dibunuh dgn detergen. Jarum suntik: sama sekali jangan dimasukkan kembali kedalam penutup jarum dan gunakan botol plastik/ kaleng pembuangan khusus untuk semua alat tajam.( Perawat yg telah dilatih )

Beberapa Aturan Pokok Keperawatan

Bersihkan ruangan seperti biasa Kamar mandi/ WC , pemeliharaan seperti biasa. Tempelkan stiker khusus dgn tulisan BAHAN MENULAR pd semua botol spesimen yg akan dikirim ke laboratorium Tangan harus selalu dicuci selama dan sesudah segala aktifitas pelayanan terhadap penderita, walaupun mempergunakan sarung tangan.

Administration

Blood Urine Oral

Blood Detection Tests

Enzyme-Linked Immunosorbent Assay/Enzyme Immunoassay (ELISA/EIA) Radio Immunoprecipitation Assay/Indirect Fluorescent Antibody Assay (RIP/IFA) Polymerase Chain Reaction (PCR) Western Blot Confirmatory test

Urine Testing
Urine Western Blot
As sensitive as testing blood Safe way to screen for HIV Can cause false positives in certain people at high risk for HIV

Oral Testing
Orasure
The only FDA approved HIV antibody. As accurate as blood testing Draws blood-derived fluids from the gum tissue. NOT A SALIVA TEST!

Treatment Options

Antiretroviral Drugs
Nucleoside Reverse Transcriptase inhibitors
AZT (Zidovudine)

Non-Nucleoside Transcriptase inhibitors

Viramune (Nevirapine)

Protease inhibitors
Norvir (Ritonavir)

Western Blot
Expensive $ 80 - 100 technically more difficult visual interpretation lack standardisation
- performance - interpretation - indeterminate reactions resolution of ??

Gold Standard confirmation

for

Polymerase Chain Reaction (PCR)

Looks for HIV DNA in the WBCs of a person. PCR amplifies tiny quantities of the HIV DNA present, each cycle of PCR results in doubling of the DNA sequences present. The DNA is detected by using radioactive or biotinylated probes. Once DNA is amplified it is placed on nitrocellulose paper and allowed to react with a radiolabeled probe, a single stranded DNA fragment unique to HIV, which will hybridize with the patients HIV DNA if present. Radioactivity is determined.

Virus isolation
Virus isolation can be used to definitively diagnose HIV. Best sample is peripheral blood, but can use CSF, saliva, cervical secretions, semen, tears or material from organ biopsy. Cell growth in culture is stimulated, amplifies number of cells releasing virus. Cultures incubated one month, infection confirmed by detecting reverse transcriptase or p24 antigen in supernatant.

Opportunistic Infection Treatment

Issued in an event where antiretroviral drugs are not available

Four ways to protect yourself?

Abstinence Monogamous Relationship Protected Sex Sterile needles

Monogamous relationship
A mutually monogamous (only one sex partner) relationship with a person who is not infected with HIV HIV testing before intercourse is necessary to prove your partner is not infected

Protected Sex

Use condoms (female or male) every time you have sex (vaginal or anal) Always use latex or polyurethane condom (not a natural skin condom) Always use a latex barrier during oral sex

When Using A Condom Remember To:

Make sure the package is not expired Make sure to check the package for damages Do not open the package with your teeth for risk of tearing Never use the condom more than once Use water-based rather than oil-based condoms

Sterile Needles
If a needle/syringe or cooker is shared, it must be disinfected:
Fill the syringe with undiluted bleach and wait at least 30 seconds. thoroughly rinse with water Do this between each persons use

The Move Toward Lower Pill Burdens

Regimen 1996
Zerit/Epivir/Crixivan 10 pills, Q8H

Dosing

Daily pill burden

1998
Retrovir/Epivir/Sustiva 5 pills, BID

2002
Combivir (AZT/3TC)/EFV 3 pills, BID

2003
Viread/ Emtriva/Sustiva

3 pills, QD 2 pills, QD

2004
Truvada/Sustiva

Truvada
Truvada is made up of HIV drugs from a class called nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs), also known as nukes. The NRTIs block reverse transcriptase, a protein that HIV needs to make more copies of itself. This may slow down HIV disease

Vaccines?
Whole virus vaccines Attenuated viruses: Essentially intact, living HIV virions that have been chemically or genetically damaged. Whole killed virus: Intact virions that have been damaged so badly that they are completely nonfunctional (dead). Subunit vaccines Clone one gene from HIV, express the protein and use it to vaccinate patients. The disadvantage is that the person only raises antibodies against one target. With free virus, the targets are mainly the envelope proteins; however, these are extremely variable proteins. Six amino acids of the V3 loop of gp120 appear to be relatively constant (some variability exists but most antibodies cross react with the variants). Antibodies against cocktails of different V3's are being tried. Nucleic Acid Vaccines Gene gun, muscle expression.

PENUTUP
Sesuai dgn sifat AIDS itu sendiri, maka pencegahan AIDS relatif mudah, yaitu menghindari pemakaian jarum suntik berganti ganti dan menghindari hubungan seksual dgn pasangan ganda. Agama dan Pancasila melarang hubungan seksual ekstra marital. Akan tetapi penggunaan jargon jargon Agama atau Pancasila dalam batasan ucapan verbal saja jelas tidak ada gunanya, bahkan bisa membuat orang tertutup terhadap informasi yang benar

Thank you!