Here are the main ways you can get HIV: - Through unprotected sex (anal, vaginal or oral) with an HIV-positive partner. HIV is found in certain bodily fluids like semen, vaginal fluids, rectal fluids, and blood. - From an HIV-positive mother to her baby during pregnancy, childbirth or breastfeeding. - By sharing needles or syringes with someone who has HIV. HIV is present in the blood of infected individuals. - Through a blood transfusion or organ/tissue transplant before March 1985 in the US, as screening tests were not available. Today, the risk from transfusions is extremely low due to screening. - Potentially through needlestick

1. What is HIV/AIDS ?
DR M MUNAWAR KHAN
BCC COORDINATOR
SINDH AIDS CONTROL PROGRAM PAKISTAN
1

2. Presenter
Dr. M. MUNAWAR KHAN
PROVINCIAL BCC COORDINATOR
ENHANCED HIV/AIDS CONTROL PROGRAM
Health Department, Govt. of Sindh
2

3. SINDH PAKISTAN 3

4. ENHANCED HIV/AIDS CONTROL PROGRAM SINDH 4

5. Sindh AIDS Control Program
• Objectives
• To create awareness of the seriousness of the
disease
 Ensure that people of Sindh are equipped with
knowledge and tools to protect themselves
 Reduce transmission of HIV and other STI infections
through blood and blood products
 In case of infection, the patient should be
encouraged to seek treatment
5

6. Infra Structure and Services
on Ground
• Provincial Implementation UNIT (PIU)
At I. I Depot, Rafique Shaheed Road near JPMC.
• Referral Lab Established for laboratory diagnosis and
confirmation of HIV/AIDS Cases & Sexually Transmitted Infections.
• Voluntary Counseling & Testing centers
21 VCT Centers have been Established for screening of HIV/AIDS cases
• STIs clinics 46 STIs Clinics have been Established at teaching and DHQ
hospitals for management of STI,s
• Establishment of Resource Center With Facilities of Digital
Library. For trainees and projects staff
• PPTCT Centers 03 (Prevention of Parents to Chid Transmission)
6

7. PPTCT Centers of Pakistan
Tertiary Hospitals:
 PIMS- Islamabad
 HMC- Peshawar
 Lady Wallingdon- Lahore
 Services- Lahore
 Civil- Karachi
 Qatar- Karachi
 Shaikh Zaid Hospital Larkano
 Sindamon- Quetta (nonfunctional)
District Headquarter Hospitals:
 DHQ Hospital, Gujrat
 DHQ Hospital, DG Khan

8. Origin of HIV

9. African Simean [Green] Chimpanzee

10. History of HIV/AIDS
HIV came from a similar virus found in chimpanzees - SIV.
HIV probably entered the United States around 1970
CDC in 1981 noticed unusual clusters of Kaposi’s sarcoma in
gay men in NY and San Francisco, which led to the disease to
be called GRID (Gay Related Immune Deficiency).
By 1982 the disease was apparent in heterosexuals and was
renamed AIDS (Acquired Immune Deficiency).
10

11. 1981 History
8 cases of KS among young gay men
June 5, 1981:
5 cases of PCP(Pneumocystis Pneumonia )
in gay men Los Angeles, San Francisco and
New York, who had developed PCP
... from UCLA (MMWR)
11
collected by Dr MZ

12. Morbidity and Mortality Weekly Report (MMWR)
MMWR SEARCH
In the period October 1980-May 1981, 5 young men, all
active homosexuals, were treated for biopsy-confirmed
Pneumocystis carinii pneumonia at 3 different hospitals in
Los Angeles, California.
Two of the patients died. All 5 patients had laboratory-
confirmed previous or current cytomegalovirus (CMV)
infection and candidal mucosal infection.
12

13. 2006 History
US National Institutes of Health revealed
the results of two African trials of male
circumcision as an HIV prevention
method with clear evidence that the
intervention reduced HIV
transmission by around 50%.
+ The WHO and other organizations
suggested they would soon begin
promoting male circumcision in areas
with severe HIV epidemics.
13
collected by Dr MZ

14. Global summary of the AIDS epidemic  2009
Number of people Total 33.3 million
Adults 30.8 million
living with HIV Women 15.9 million
Children (<15 years) 2.5 million
Total 2.6 million
People newly infected Adults 2.2 million
with HIV in 2009 Children (<15 years) 370 000
AIDS deaths in 2009 Total 1.8 million
Adults 1.6 million
Children (<15 years) 260 000

15. Over 7000 new HIV infections a day in 2009
 About 97% are in low and middle income
countries
 About 1000 are in children under 15 years of
age
 About 6000 are in adults aged 15 years and
older, of whom:
─ almost 51% are among women
─ about 41% are among young people (15-24)

16. 16

17. HIV/AIDS in Pakistan
•Pakistan is going through a transition of the HIV
epidemic; from a low Prevalence state to a
concentrated epidemic.
•Although the estimated prevalence among the
general population is less than 0.1% in the country,
• Recent surveillance results clearly indicate that
the epidemic is becoming established among
certain high risk groups (HRGs).
17

18. Pakistan’s HIV epidemic
•At present the most prominent face of
Pakistan’s HIV epidemic are the IDUs.
•In this regards, Pakistan is following the Asian
Epidemic Model,
•where the HIV epidemic first establishes among
IDUs and then spreads to the rest of the population via sex
workers who have sexual contact with IDUs.
18

19. SUGGESTIVE HISTORY & RISK FACTORS
RISK FACTORS/RISK BEHAVIOURS
• People with multiple sexual partners
• People with recent or prior STDs
• Commercial sex workers & their partners
• Homosexuals
• Travelers to high prevalence areas
• Sexually active injection drug users
• Sexual partners of at risk persons
• Recipients of blood products prior to HIV
screening
• Children born to HIV positive mothers

20. But HIV/AIDS does not
discriminate
Everybody is vulnerable.
The virus is not restricted
to any age group, race,
social class, gender, or
religion. In many countries
of Asia and the Pacific
HIV/AIDS has spread to
the general population.
20

21. Pakistan’s HIV epidemic
A combination of risk factors is currently
putting Pakistan at serious risk of further
transmission from high to low risk groups
through bridging populations.
21

22. Example of high risk sexual networks in
a population
FSW Male Clients
IDU
General Population
MSW
Women

23. 23

24. HISTORY OF HIV IN PAKISTAN
• 1986 – An African Sailor Died in Karachi
• 1987 – First Pakistani Citizen Diagnosed with
AIDS in Lahore
• 1987 – First Husband-Wife-Child transmission of
HIV occurred in Rawalpindi
• 1993 – First Breastfed Baby gets AIDS in
Karachi
• 2003 First outbreak among Injecting Drug
Users was identified in Larkana
24

25. HIV & AIDS in Pakistan
(2nd Quarter 2010)
• Total Estimated Cases = 106000
• Total reported HIV & AIDS cases in the country
are = 7574
• HIV Positive – 7049
• AIDS Cases – 525

26. HIV/AIDS IN SINDH PAKISTAN
26

27. SINDH
Upto September 30,2011
TOTAL CASES = 4325
HIV Asymptomatic Cases= 4130
Male = 3885 94.07 %
Child = 23 0.56%
Female = 205 4.96%
Child = 17 0.41%
AIDS CASES = 195
Male = 164 (84.10 %)
Child = 01 (0.51%)
Female = 29 (14.87)
Child = 01 (0.51%)

28. DEATH CASES TILL
30th September 2011
DEATH = 140
Male = 122 87.14%
Child = 02 1.43%
Female = 10 7.14%
Child = 06 4.29%
28

29. • Sindh is in the concentrated phase of
epidemic among :
• IDU’s = 27%
• Hijra Sex workers =15.45%
29

30. • HIV epidemic is still considered ‘low’ or ‘concentrated,’
confined mainly to individuals who engage in high risk
behaviors,
• An epidemic is considered ‘concentrated’ when less
than one per cent of the general population but more
than five per cent of any ‘high risk’ group are HIV-
positive
• An epidemic is considered ‘generalized’ when more
than one per cent of the population is HIV-positive.
30

31. AIDS
31

32. H Human
I Immunodeficiency
V Virus

33. HIV ?
• HIV is different from most other viruses because it attacks
the immune system
• The immune system gives our bodies the ability to fight
infections.
• HIV finds and destroys a type of white blood cell WBC (T
cells or CD4 cells) that the immune system must have to
fight disease.
• People can live a long healthy life with HIV without
symptoms, even without medications.
• Once the immune system begins to break down over time,
and the person develops more symptoms,
• This often means they have progressed to AIDS.
33

34. Caused by immune deficiency virus
• HIV-1
• HIV-2

35. Genetic Subtypes of HIV
• Groups : HIV 1 , HIV 2
• Genetic subtypes :
Groups : HIV 1- M(main),O(outlier),N (new)
Subtypes(clades) M(11 subtypes A-I,CRF)
HIV 2—Six subtypes A-F

39. DIFFERENCE B/W HIV-1 & HIV-2
• HIV-1 and HIV-2 are closely related, they are thought
to have jumped from primates to humans at
different times (and from different species).
• HIV-1 is more easily transmitted, it also spreads
more readily and therefore accounts for the vast
majority of global HIV infections.
• HIV-2, is much less transmittable, is largely confined
to West Africa (where it is thought to have
originated) and to West African migrant communities
in Europe.
39

40. DIFFERENCE B/W HIV-1 & HIV-2
• HIV-1 also mutates more efficiently that HIV-2
and generally progresses to AIDS at a
significantly faster rate than HIV-2 does.
• Also, HIV-2 has Vpr and Vpx proteins. HIV-1
has only Vpr.
• Differences between these proteins are
actually on research.
40

41. HIV-1 and HIV-2 Infections
• HIV-2 has the same genetic organization as
HIV-1 but there are significant differences in the
envelope glycoprotein
• Similar diseases associated with both HIV-1 and
HIV-2 but most west Africans remain asymptomatic
• Progression from HIV to AIDS is faster in HIV-1 as
compared to HIV-2, either it is less pathogenic or it
has a long period of latency
• HIV-2 infected children have far better survival rates

42. VIROLOGY / LIFE CYCLE
• HIV is a retrovirus belonging to the family of
Lentivirus
• Able to use the RNA and the host DNA to
make viral DNA
• Long incubation period/Clinical latency

43. THE HIV LIFE CYCLE
CONTINUOUS VIRAL REPLICATION LEADING TO
IMMUNODEFICIENCY IS THE
HALLMARK OF THE DISEASE!!

44. ! The Immune System
T Cells (CD4 Cells) = Part of body’s immune system
CD4
The average person has between 800 & 1500 CD4
cells per cubic millimetre of blood
The immune system helps fight diseases
CD4 Disease Disease
IMMUNE ATTACKS DISEASE KILLS DISEASE
SYSTEM

45. HIV and the Immune System
When HIV enters the body it must enter a cell to live and reproduce. The HIV
virus attacks CD4 cells, eventually killing them
CD4 HI
HIV V
HIV HI CD4
V HI
V
HIV Enters CD4 Cells HIV Replicates Kills CD4
Cells
The newly produced HIV then moves into new CD4 cells and infects them.
The body’s immune system tries to replace the lost CD4 cells, but over
time it is unable to keep these levels up.

46. HIV-Infected T-Cell
HIV HIV Infected New HIV
T-Cell T-Cell Virus
Virus

47. VIROLOGY
gp 120 & gp 41 have the major role to recognize CD 4 cells
thus promoting attachment

48. HIV Replication
• HIV is a retrovirus.
• Viral envelope protein gp120 and gp41 attach to the CD4 antigen
complex on host cells
• CD4 found on T helper lymphocyte,B lymphocytes, monocytes
and tissue macrophages.
• HIV uses RT to convert RNA to DNA
• HIV DNA enters nucleus of CD4 cell and integrates into host
DNA.
• HIV DNA instructs cell to make copies of original virus.
• New virus particles are assembled and leave cell, ready to infect
other CD4 cells.

50. Viral RNA yellow,DNA blue
Reverse Transcription
Attachment Entry of the Viral RNA
Reverse Transcriptase
Inhibitor (red) Integration of Viral DNA Transcription: Back to RNA
Translation: RNA -> Proteins Protease Inhibitors
Viral Protease
Assembly and Budding

52. HIV Transmission
• HIV enters the bloodstream through:
– Open Cuts
– Breaks in the skin
– Mucous membranes
– Direct injection

53. MODES OF TRANSMISSION
• Blood/Blood products, tissues, organs- More
than 90%
• Sexual Intercourse - 0.1 to 1% (however
frequency is high causing high rate of
infection)
• IDU – 0.5 to 1 %
• Parent to child – 30%
53

54. HIV Modes of Transmission
1. Sexual
2. Infected blood and blood products
3. Mother to Child

55. HIV Modes of Transmission Cont’d…
1. Sexual:
• Through sex with infected man or woman.
• Transmit by Hetrosexual & Homosexual and
Bisexual Practice
• Ulcerative STIs increases the risk of infection
several folds

56. HIV Modes of Transmission Cont’d…
2. Infected blood and blood products
• Contaminated Blood/Blood Products transfer
• Organ/Tissue Transplants
• Use of Contaminated Syringes and Needles
• Tattooing
• Ear piercing etc.

57. HIV Modes of Transmission
Cont’d…
3. From mother to child
(Vertical)
• Pregnancy
• Delivery
• Lactation

58. HIV/AIDS
Interflow Communications

59. Press ad Option 1
59

60. How you catch up HIV?
• The virus spread from human to human by body fluids : Blood,
Semen, female vagina fluids and mother milk.
• HIV do spread in full sexual Intercourse that include penetration to female vagina
or the rectum without the use of Condom, and that’s because its lives within the
human fluids, as mention above.
• HIV also do spread by using common needle, because AIDS lives in the blood, due
to that fact, drugs addict are extremely vulnerable for HIV infection.
• HIV is spreading by a breast feeding, because it can live within mother milks.

61. HIV Transmission cont’d…
• Common fluids that are a means of transmission:
– Blood
– Semen
– Vaginal Secretions
– Breast Milk
– Saliva

62. ? How can you get HIV?
1. Through these bodily fluids
VAGINAL BREAST
SECRETIONS MILK
BLOOD
CERVICAL
SECRETIONS
SEMEN
2. Through these acts:
H
INFECTED MOTHER: UNPROTECTED PENETRATIVE 1. INJECTION OR TRANSFUSION OF INFECTED
DURING INTERCOURSE (HOMOSEXUAL OR BLOOD / BLOOD PRODUCTS
1. PREGNANCY HETEROSEXUAL) WITH SOMEONE 2. SHARING UNSTERILISED NEEDLES WITH
2. BIRTH WHO IS INFECTED SOMEONE WHO IS INFECTED
3. BREAST FEEDING
62

63. HIV in Body Fluids
Blood
Semen
18,000 Vaginal
11,000
Fluid Amniotic
7,000 Fluid
4,000 Saliva
1
Average number of HIV particles in 1 ml of these body fluids

64. TRANSMISSION RISK AFTER EXPOSURE
• 95% for blood and blood products
•15-40% for vertical transmission
• 0.5% -1.0% for injection drug use
• 0.2-0.5% for for genital mucous membranes
•< 0.1% for non genital mucous membranes
• Needle stick injury : 1 in 300
World wide major route of transmission
Heterosexual(70%)
Transmission

65. Estimated PPTCT Rates
Without intervention
During pregnancy 5–10%
During labour and delivery About 15%
During breastfeeding 5-20%
MTCT infection rates = up to 40%

66. HIV Routes of Transmission
Sexual Contact: Male-to-male
Male-to-female or vice versa
Female-to-female
Blood Exposure: Injecting drug use/needle sharing
Occupational exposure
Transfusion of blood products
Perinatal: Transmission from mother to baby
Pregnancy, delivery and breastfeeding

67. HIV Infection and Antibody Response
---Initial Stage---- ---------------Intermediate or Latent Stage-------------- ---Illness Stage---
Flu-like Symptoms
Or Symptom-free AIDS Symptoms
No Symptoms
----
Infection Virus
Occurs
Antibody
----
< 6 month ~ Years ~ Years ~ Years ~ Years

68. Natural History of HIV Infection

69. Window Period
• This is the period of time after becoming infected
when an HIV test is negative
• 90 percent of cases test positive within three months
of exposure
• 10 percent of cases test positive within three to six
months of exposure

70. Infections in relation to CD4+ cell
count
400
Herpes Zoster
Tuberculosis
300
Oral Candidiasis
200 PCP
Esophageal Candidiasis
A Mucocutaneous herpes
100
I Toxoplasmosis
Cryptococcosis
D (Mycobacterium avium complex ) MAC
(Cytomegalovirus) CMV
50
S (Progressive Multifocal Leuko encephalopathy) PML
Cryptosporiodiosis
Time

71. AIDS
• A Acquired
• I Immunity
• D Deficiency
• S Syndrome
It destroys the immune system of infected person.

72. After HIV infection (without ARV)
• Most will develop AIDS 8-10 years later
• 5-10% will develop AIDS first few years
• 5-10% will not progress to AIDS for 15 or
more years
Evaluation

73. HIV Risk Reduction
• Avoid unprotected sexual contact
• Use barriers such as condoms
• Limit multiple partners by maintaining a long-
term relationship with one person

74. Infectious
• Aids can’t be spread in a full sexual
intercourse with condom because the
condom prevents infected body fluids.

75. How you watch out?
Using condom every time you are making an
intercourse. Aids have not yet come with vaccine or
remedies that bring for a recovery.
Condom is the only tool for preventing infection with
AIDS during an intercourse. Those are the facts, this
is your life, think good and decide how you want to
behave.

76. HIV Risk Reduction Cont’d…
Condoms
Using condoms is not 100 percent effective in
preventing transmission of sexually transmitted
infections including HIV
Condoms = Safer sex
Condoms ≠ Safe sex

77. HIV Risk Reduction Cont’d…
Condom Use
• Should be used consistently and correctly
• Should be the responsibility of both partners
for the protection of both partners
• Male and female condoms are available

78. Female initiated methods of prevention
• Female condoms: 97% effective yet currently only manufactured
by one company and too expensive
• Microbicides: gel, film, sponge, lubricant or suppository. Still in
development
User controlled, protection against HIV/STIs, could be available
in contraceptive and non-contraceptive forms.
Researchers predict a microbicide that is only 60% effective
could prevent more than 2.5 million infections within three years
of its introduction.
Currently in clinical trials and may be available over the counter
within 5-7 years

79. Press ad Option 3
79

80. HIV Risk Reduction Cont’d…
• Avoid drug and alcohol use to maintain good
judgment
• Don’t share needles used by others for:
Drugs
Tattoos
Body piercing
• Make sure GP is using a new syringe
• Avoid exposure to blood products

81. Drugs Alcohol and
•
Aids Drugs and
What the connection between
Alcohol?
• Alcohol and drugs causing you for
misjudgment, so if you drunk you can,t better
follow the rules of safe sex, and for drugs
injections, can transpose the virus.

82. People Infected with HIV
• Can look healthy
• Can be unaware of their infection
• Can live long productive lives when their HIV
infection is managed
• Can infect people when they engage in high-risk
behavior

83. How you know?
• You can’t identify a person who carry HIV
and in most cases, he/she himself doesn’t know about it. You can
found out the virus only in HIV tests. A person can carry the virus for
many years, he can be seen, feel and function as usual,.
• Don’t hope from your partner to tell you, that he/she carry the HIV
virus. Because most people living with the virus are feared from
rejection and anger, even though you love each other.
• The responsibility defending your health is only in your hands!

84. HIV Exposure and Infection
• Some people have had multiple exposures without
becoming infected
• Some people have been exposed one time and
become infected

85. HIV AIDS
• Once a person is infected s/he is always infected
• Medications are available to prolong life but they do
not cure the disease
• Those who are infected are capable of infecting
others without having symptoms or knowing of the
infection

86. Suggested tips
• To reduce the risk you have to…
• Avoiding from ejaculation in your mouth
• Avoiding sucking woman sexual organ during
period.
• Avoiding from swallowing female secreting
• Make sure no active herpes wounds or others
wounds
Suggested not to brush your teeth two
hours, because of gums sensitivity

87. Not Transmitted
By
Shaking Hands
• HIV/AIDS doesn’t Spread in a hand shaking,
because the virus doesn’t live in air or on skin.

88. Not Transmitted By
Hugging
• HIV/AIDS doesn’t Spread in a Hugging, because
the virus doesn’t live in air or on skin.
88

89. Not Transmitted By
KISS
• Because in the spittle they are enzymes that
neutralized the virus. but…..?
89

90. infectious
• HIV/AIDS doesn’t spread by drinking
from the same cup, glass, using, plate,
spoons etc. because it can’t live in air or
spittle.

91. So we can live together and don’t
Discriminate or Stigmatize the peoples
leaving with HIV/AIDS.
91

92. HIV is NOT Transmitted via
 Casual contact
Tears, sweat and saliva
Coughing and sneezing
Not transmitted via Mosquitoes,
Fly, Bee, Buds etc.

93. Infectious
• Aids doesn’t spread by a mosquito bite
because mosquito can’t carry the
human virus of HIV

94. HIV DOES NOT SPREAD
IN THESE WAYS
94

95. Press ad Option 4
95

96. Challenges
• Break the silence on HIV and AIDS
• End stigmatization and discrimination of
PLWHA
96

97. Facts about AIDS
• No Curative Treatment available.
• No Vaccine.
BUT IT CAN BE PREVENTED
97

99. 99