PBH101 Lecture # 7.ppt

Dr.Shaikh Abdus Salam
Introduction to Public Health
Module # 5
Lecture # 7
Re-emerging infectious diseases, HIV/AIDS, TB.
DR. SHAIKH ABDUS SALAM
Dept. of Public Health
North South University

By the end of this lecture you will be able to:
o Conceptualize
• HIV/AIDS, risky groups for getting HIV/AIDS
• Mode of transmission & prevention
• Current situation of HIV/AIDS in Bangladesh
o Understand the use of Anti-retroviral therapy in treating AIDS
cases in Bangladesh.
OBJECTIVES OF THE LECTURE
Dr. Shaikh Abdus Salam 1

HIV
• HIV: Human Immunodeficiency Virus
– Spread through contact with the blood, semen, pre-seminal fluid, rectal
fluids, vaginal fluids, or breast milk of a person infected with HIV
• HIV transmission is possible at any stage of HIV infection—even
if an HIV-infected person has no symptoms of HIV

AIDS
• AIDS: Acquired Immunodeficiency Syndrome
• Most advanced stage of HIV infection
• Time varies, may take 10 years or more
• How AIDS diagnosed:
– CD4 count (white blood cell) < 200 cells/mm3
– Normal CD4 count ranges 500- 1,600 cells/mm3.
AND/OR
– The person has one or more opportunistic infections
(occur more frequently and are more severe in
individuals with weakened immune systems)

AIDS
• HIV/AIDS claimed 33 m lives so far.
• 38.1 m people living with HIV/AIDS at the end of
2019
• Due to presence of Preventive, diagnostic and
curative care HIV is now a manageable chronic
health condition.

Structure of HIV

Key facts
1. HIV continues to be a major global public health issue, having claimed 36.3 million [27.2–47.8 million]
lives so far.
2. There is no cure for HIV infection. However, with increasing access to effective HIV prevention,
diagnosis, treatment and care, including for opportunistic infections, HIV infection has become a
manageable chronic health condition, enabling people living with HIV to lead long and healthy lives.
3. There were an estimated 37.7 million [30.2–45.1 million] people living with HIV at the end of 2020, over
two thirds of whom (25.4 million) are in the WHO African Region.
4. In 2020, 680 000 [480 000–1.0 million] people died from HIV-related causes and 1.5 million [1.0–2.0
million] people acquired HIV.
5. To reach the new proposed global 95–95–95 targets set by UNAIDS, we will need to redouble our efforts
to avoid the worst-case scenario of a half million excess HIV-related deaths in sub-Saharan Africa,
increasing HIV infections due to HIV service disruptions during COVID-19, and the slowing public health
response to HIV.
• The human immunodeficiency virus (HIV) targets the immune system and weakens people's defense against many infections and
some types of cancer that people with healthy immune systems can fight off. As the virus destroys and impairs the function of
immune cells, infected individuals gradually become immunodeficient. Immune function is typically measured by CD4 cell count.
• The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS), which can take many years to develop
if not treated, depending on the individual. AIDS is defined by the development of certain cancers, infections or other severe long-
term clinical manifestations.

Some important terminologies
• PrEP: Pre-Exposure Prophylaxis is an HIV prevention option for people who don’t have
HIV but who are at high risk of becoming infected with HIV. PrEP involves taking a
specific HIV medicine every day. PrEP should always be combined with other
prevention options, such as condoms.
• PEP: Post-exposure prophylaxis involves taking antiretroviral (ARV) medicines very
soon (within 3 days) after a possible exposure to HIV to prevent becoming infected with
HIV.
• ART: antiretroviral therapy is the use of HIV medicines to treat HIV infection. ART
involves taking a combination of HIV medicines every day. ART can’t cure HIV infection,
but it can help people infected with HIV live longer, healthier lives. HIV medicines can
also reduce the risk of transmission of HIV.
• VMMC: Voluntary Medical Male Circumcision– In 2020 WHO updated the 2007
recommendation of VMMC to continue as an additional preventive intervention among
males age 15 years and older. Over 15 million VMMC performed between 2015-2019.

Important information
• ARVs # Anti Retro Viral drugs
• Window Period # within 28 days of the infection,
the antibody did not develop, no +ve test result
and no sign/symptoms; but cases are
transmitting the virus.

Signs and symptoms
• The symptoms of HIV vary depending on the stage of infection. Though
people living with HIV tend to be most infectious in the first few months after
being infected, many are unaware of their status until the later stages. In the
first few weeks after initial infection people may experience no symptoms or an
influenza-like illness including fever, headache, rash or sore throat.
• As the infection progressively weakens the immune system, they can develop
other signs and symptoms, such as swollen lymph nodes, weight loss, fever,
diarrhoea and cough. Without treatment, they could also develop severe
illnesses such as tuberculosis (TB), cryptococcal meningitis, severe bacterial
infections, and cancers such as lymphomas and Kaposi's sarcoma.

AIDS with Cancer

Sources of HIV/AIDS
• Body fluids of a HIV infected person.
• 1. Fluids contain highly concentrated virus:
• a) CSF b) Semen c) Blood d) pre-semen
• 2. Fluids contain less concentrated virus
• a) Cervical secretion, b) Vaginal secretion c) Breast milk
3. Fluids contain very less concentrated virus:
a) Sweat) Saliva c) Tears etc.

Mode of Transmission
• 1. Sexual transmission: Unsafe sexual act. Anal sex.
• 2.Perentral transmission: infected blood and blood products
• 3.Perinatal transmission: from an infected mother to her offspring during,
before or after delivery. 25%-50%
• 4. Accidental transmission: Infected needles, syringes, organ
transplants, semen and other tissues can occur in medical settings

HIV Transmission
• HIV can be transmitted via the exchange of a variety of body fluids from
infected people, such as blood, breast milk, semen and vaginal secretions.
HIV can also be transmitted from a mother to her child during pregnancy and
delivery. Individuals cannot become infected through ordinary day-to-day
contact such as kissing, hugging, shaking hands, or sharing personal objects,
food or water.
• It is important to note that people with HIV who are taking ART and are virally
suppressed do not transmit HIV to their sexual partners. Early access to ART
and support to remain on treatment is therefore critical not only to improve the
health of people with HIV but also to prevent HIV transmission.

High risk group or Key populations
Key populations:
1. MsM
2. CSWs with clients
3. People in Prison/jail/goal and other closed setting
4. IDUs
5. Transport workers
6. Migrant population
7. Female garments workers in Dhaka city etc.

Risk factors
• Behaviours and conditions that put individuals at greater
risk of contracting HIV include:
1. having unprotected anal or vaginal sex;
2. having another sexually transmitted infection (STI) such as syphilis, herpes,
chlamydia, gonorrhoea and bacterial vaginosis;
3. sharing contaminated needles, syringes and other injecting equipment and
drug solutions when injecting drugs;
4. receiving unsafe injections, blood transfusions and tissue transplantation,
and medical procedures that involve unsterile cutting or piercing; and
5. experiencing accidental needle stick injuries, including among health workers

Other vulnerable groups
Adolescent girls and young women in southern
and eastern Africa

Control of HIV/AIDS
• For control of AIDS, measures have to be
addressed to
A. Cases.
B. Carriers
C. Contacts
D. The community

Prevention
1. Health education
2. Condom promotion
3. VCT: rapid test and self test.
4. Pre Ep: 1st pill 2 hours before sex
2nd pill 24 hours before sex
3rd pill after 24 hours of first 2 pills
4th pill 48 hours after first 2 pills
The formula is 2+1+1
There is IM injection (on Trial) CAB-LA (cabotegravir) will be available at the end
of 2022. This is one every 8 weeks.
5. DVR# Dapivirine vaginal Ring (LMIC)

Prevention
• Individuals can reduce the risk of HIV infection by limiting
exposure to risk factors. Key approaches for HIV prevention,
which are often used in combination, include:
1. male and female condom use;
2. testing and counselling for HIV and STIs;
3. testing and counselling for linkages to tuberculosis (TB) care;
4. voluntary medical male circumcision (VMMC);
5. use of antiretroviral drugs (ARVs) for prevention;
6. harm reduction for people who inject and use drugs; and
7. elimination of mother-to-child transmission of HIV.

Treatment
• HIV disease can be managed by treatment regimens composed of a combination of three or more antiretroviral
(ARV) drugs. Current antiretroviral therapy (ART) does not cure HIV infection but highly suppresses viral
replication within a person's body and allows an individual's immune system recovery to strengthen and regain
the capacity to fight off opportunistic infections and some cancers.
• Since 2016, WHO has recommended that all people living with HIV be provided with lifelong ART, including
children, adolescents, adults and pregnant and breastfeeding women, regardless of clinical status or CD4 cell
count.
• By June 2021, 187 countries had already adopted this recommendation, covering 99% of all people living with
HIV globally. In addition to the treat all strategy, WHO recommends a rapid ART initiation to all people living with
HIV, including offering ART on the same day as diagnosis among those who are ready to start treatment. By
June 2021, 82 low- and middle-income countries reported implementation. that they have adopted this policy,
and approximately half of them reported country-wide
• Globally, 27.5 million [26.5–27.7 million] people living with HIV were receiving ART in 2020. This equates to a
global ART coverage rate of 73% [56–88%]. However, more efforts are needed to scale up treatment,
particularly for children and adolescents. Only 54% [37–69%] of children (0–14 years old) were receiving ART at
the end of 2020.

WHO- Recommonded “5 Cs”
Principles WHO-recommended, “5 Cs”:
 Consent (Informed)
Confidentiality
Counselling
Correct test results
Connection ( Linkage to cases, treatment and
other services)

HIV/AIDS in Bangladesh
• 1st case was detected in 1989
• Overall prevalence is less than 1%
• BUT high level among injecting drug users- 7% in one part of Dhaka city
• Limited access to voluntary counseling and testing services
• Extremely vulnerable on HIV epidemic due to:
– Poverty
– Over population
– Gender inequality
– Transactional sex

Tuberculosis (TB)
• Caused by bacteria
• Usually attack the lungs
• Can also attack any part of the body- kidney, spine,
and brain
• Transmission
– Through the air from one person to another
– Coughs, sneezes, speaks, or sings
– Nearby people may breathe in these bacteria and
become infected

TB
• TB is the most common illness among people
living with HIV. Fatal if undetected/ untreated. TB
is the leading cause of death among people with
HIV. 33% of all HIV death (Earlier)
• TB HIV TB.

TB with AIDS Patient

• Latent TB infection
– People who are infected, but not sick
– Do not feel sick, do not have any symptoms, and cannot
spread TB to others
– Some people with latent TB infection go on to get TB
disease
• TB disease
– Immune system can’t stop TB bacteria from growing
– The bacteria begin to multiply in the body and cause TB
disease
– The bacteria attack the body and destroy tissue . If this
occurs in the lungs, the bacteria can actually create a hole
in the lung

DOTS
• Directly Observed Treatment Short course
(DOTS)
– Meet with a health care worker every day or several times a week
– Meet at a place you both agree on: TB clinic, your home or work, or any
other convenient location
– Take your medicines at this place while the health care worker watches
– May need to take medicines only 2 or 3 times each week instead of every
day

Treating Tuberculosis and
HIV/AIDS Together
• Generally the priority is to initiate treatment for TB
• Depending on clinical indications, starting ART
– after the initial phase of TB treatment is completed OR
– after the entire course of TB treatment is completed
• If indicated, treatment for both HIV and TB can be started parallel, but careful
management is needed
• When a patient with HIV-associated TB who has been started on ART and TB treatment
simultaneously experiences a paradoxical worsening with exacerbation of symptoms,
signs
• Paradoxical reaction occurs from
– a reconstitution of the immune system and
– may be accompanied by a high fever, expanding central nervous system lesions,
and worsening of chest x-ray findings

Fast-Track-Target
UNAIDS 90-90-90 strategy: From 2.1 million cases
in the year 2010 to 500000 by 2020.
1. 90% Dx by 2020
2. 90% ART by 2020
3. 90% viral suppression by 2020

Fast- Track-Target
• The UNAIDS strategy will end the HIV pandemic
by the year 2030 and the strategy is:
• 95-95-95 and the HIV cases will be fewer than
200000.

This Photo by Unknown Author is licensed under CC BY-SA

•THANK YOU

PBH101 Lecture # 7.ppt

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