Вич проявления у женщин: 5 первых симптомов ВИЧ заболевания у женщин на СпросиВрача

Большинству из нас кажется, что проблема ВИЧ их никогда не коснётся, ведь даже в свободных отношениях нормальные взрослые люди следят за своим здоровьем и не ведут асоциальный образ жизни. Но врачи бьют тревогу, положительный результат теста на ВИЧ становится нормой практически для каждого второго заражённого.

Фильм Юрия Дудя «ВИЧ в России — эпидемия, про которую не говорят» вызвал резонанс и привлёк большое внимание к этой проблеме. В нашей стране уже больше миллиона ВИЧ-заражённых, и число их растёт. Несмотря на то что часто на ранней стадии болезнь протекает бессимптомно, некоторые «тревожные звоночки» могут дать понять, что вы заразились.

— Длительное время инфекция может вообще не проявляться. И человек может понять, что он заражён, только если пройдёт тест на ВИЧ, — отметила заведующая отделом эпидемиологии и профилактики Московского областного центра по профилактике и борьбе со СПИДом Евгения Жукова. — Однако некоторые признаки могут прояснить ситуацию.

По словам врача-эпидемиолога по профилактике ВИЧ Вячеслава Троцака, первые признаки заражения ВИЧ у мужчин и женщин могут появиться только через один-два месяца после контакта с носителем вируса. Иногда болезнь протекает бессимптомно годами.

Хроническая простуда, грипп или ангина

Пациента могут беспокоить симптомы, которые обычно проявляются при гриппе и ангине. Нёбные миндалины отекают, покрываются белесоватым налётом. Если у человека хронический тонзиллит, то у него может наблюдаться обострение. По статистике, около половины мужчин и женщин испытывают «гриппоподобный» синдром при ВИЧ-инфекции.

— Коварство ВИЧ заключается в том, что первые признаки очень напоминают обычную простуду и так же быстро проходят, — отметил руководитель программ фонда по борьбе со СПИДом «Шаги» Кирилл Барский.

Длительное время высокая температура

Может наблюдаться повышающаяся длительное время температура от 37,1 до 38 °C. Это реакция организма на вторжение вируса. Если температура наблюдается на фоне пониженного уровня лейкоцитов — это плохой знак.

Беспричинная хроническая усталость

Она проявляется, когда отдых не помогает восстановиться. Может наблюдаться нарушения сна, концентрация внимания снижается, возможны нарушения памяти. При хронической усталости может также наблюдаться смена настроения от апатии до агрессии.

Боль в мышцах и суставах

Артралгия, или боль в суставах, наблюдается у 45% людей, заболевших ВИЧ. У трети инфицированных может наблюдаться мышечная боль. На ранней стадии это доставляет дискомфорт, на поздней стадии болезни (если не приняты меры) любое движение будет вызывать нестерпимую боль.

Увеличение лимфоузлов

Лимфатическая система стоит на страже организма, очищая его от токсинов, микробов и инородных тел. Всё это накапливается в лимфоузлах, а затем уничтожается с помощью клеток иммунной системы. Если количество токсинов, микробов и инородных тел резко увеличивается так, что иммунная система не справляется, лимфоузлы увеличиваются и воспаляются.

Сыпь на теле, сухость кожи

Кожа — важнейший индикатор состояния здоровья. ВИЧ наносит серьёзный удар по иммунитету, что отражается в том числе на кожном покрове. Практически у всех заболевших ВИЧ на ранней стадии наблюдаются высыпания. На раннем этапе развития болезни такая сыпь может быть воспринята как обычная аллергическая реакция. Сначала появляются небольшие покраснения, крапивница, шелушение кожи. Впоследствии это может перерасти в волдыри, гнойники, язвочки.

Повышенное потоотделение по ночам

Это довольно распространённый симптом у ВИЧ-положительных людей. Во время инкубационного периода повышенная потливость может быть не очень продолжительной и проявляться в течение одной недели. На более поздних стадиях она проявляется, если делать перерывы в приёме антиретровирусных лекарств. В любом случае повышенная ночная потливость, проявляющаяся на протяжении длительного времени, свидетельствует о серьёзных проблемах со здоровьем.

Потеря веса и мышечной массы

На ранней стадии этот симптом может не проявляться так резко, как в хронической и терминальной стадии. Потеря веса объясняется тем, что организм заражённого человека даже в стадии покоя расходует на 10% больше энергии, чем организм здорового. Потеря веса при ВИЧ отличается от потери веса при голодании. Соблюдая диету, вы сжигаете жир. При заражении ВИЧ страдают мышечные ткани, что сильно деформирует массу тела.

Головные боли

По статистике, около половины ВИЧ-положительных пациентов жалуются на регулярные головные боли. Около половины из них сталкиваются с хронической мигренью, для которой характерны тошнота, болезненная реакция на свет, пульсирующая боль. Регулярная головная боль может быть побочным эффектом антивирусной терапии.

На более поздних стадиях больные могут испытывать сильный озноб, проблемы с дыханием, проблемы с памятью, на теле могут появляться язвы. Нередко проявляются токсоплазмоз и пневмония. Современная медицина позволяет избежать этих последствий, если вовремя начать лечение.

Специалист Евгения Жукова рекомендует не заниматься самодиагностикой, если вы подозреваете возможность заражения через половой контакт с непроверенным партнёром или в случае инъекций без соблюдения правил гигиены. Анализ можно сдать бесплатно и анонимно в любом СПИД-центре.

90000 Endocrine Manifestations of HIV Infection 90001 90002 1. Introduction 90003 90004 Human Immune deficiency Virus (HIV) infection has assumed pandemic proportion since after its identification as the causative agent of Acquired Immunodeficiency Syndrome (AIDS) .The spectrum of HIV infection and AIDS is quite wide and variable. HIV infected patients have an increased risk of developing endocrine abnormalities [1]. The endocrine glands are affected in a variety of ways such as functional derangement, direct effects of HIV infection and the resultant immune suppression, effects of opportunistic infections both acute and chronic, invasion by neoplasms and the effects of the various medications used to treat HIV or any of the opportunistic infections associated with it (Table 1).While endocrine dysfunction has not been a prominent clinical feature of AIDS, all endocrine glands may be affected by the opportunistic infections and malignancies; as a result of antiretroviral treatment or indeed as a result of the direct invasion of the glands by the virus (Table 2). The introduction of anti-retroviral (ARV) drugs has significantly reduced both morbidity and mortality attributable to HIV infection [2]. The prolonged administration of these drugs however, has led to new challenges for both physicians and patients [3- 8].90005 90004 Apart from the effects of acute and chronic illnesses, the relentless progression of immune dysfunction in AIDS affects endocrine function through the activation of several cytokines, chemokines and antibody formation. The use of protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) is associated with multiple abnormalities in glucose and lipid metabolism such as insulin resistance, increased triglycerides and increased levels of low-density lipoprotein cholesterol.These metabolic disturbances might be due to a combination of factors, including the direct effect of medications, restoration to health; HIV disease as well as individual genetic predisposition. Of the available antiretroviral medications, indinavir had been associated with causing the most insulin resistance and ritonavir with causing the most hypertriglyceridemia. 90005 90008 90009 90010 90011 90012 a. Destruction of endocrine tissue 90013 90014 90015 90010 90017 • Cancer 90018 • Infection 90018 • Haemorrhage 90018 • Non-specific inflammation 90014 90015 90010 90011 90012 b.Interference with Endocrine function 90013 90014 90015 90010 90017 • Acute illness 90018 • Chronic illness 90018 • Cytokines (tumour necrosis factor, interleukin-1, interferon) 90018 • Antibodies 90014 90015 90010 90011 90012 c. Effects of medications 90013 90014 90015 90010 90017 • ARV’s 90018 • Anti Tuberculosis drugs. 90018 • Antifungal drugs. 90018 • Antiviral drugs. 90018 • Antibiotics. 90014 90015 90050 90051 Table 1. 90052 90004 Mechanisms of Endocrine dysfunction in patients with HIV [1] 90005 90008 90009 90010 90011 90012 a.Endocrinopathies as a result of direct effects of the virus. 90013 90014 90015 90010 90017 • HIV adrenalities and impaired adrenal reserve 90018 • Hypercorticolism 90018 • Idiopathic adrenohypophyseal necrosis 90018 • Hyperprolactinaemia 90018 • Primary hypogonadism 90018 • Growth factor 90018 • AIDS wasting syndrome 90014 90015 90010 90011 b. Endocrinopathies as a resultof structural destruction of gland.s 90014 90015 90010 90017 • Cytomegalovirus (CMV) adrenalitis 90018 • Pneumocystis thyroiditis 90018 • Mycobacterial infection, cryptococcosis, toxoplasmosis (pituitary, thyroid, adrenals) 90018 • Haemorrhages and abscesses causing insufficiency of glands (pituitary , thyroid and adrenals) 90014 90015 90050 90051 Table 2.90052 90004 Common Endocrine abnormalities in HIV infected patients [1]. 90005 90002 2. The pituitary 90003 90004 Involvement of the pituitary gland is common in advanced HIV infection, at autopsy; varying degrees of infarction and necrosis are the most common findings occurring in nearly 10% of cases [1]. Also common are opportunistic Infections by CMV, Pneumocystis carinii, Toxoplasmosis and mycobacteria among others [9]. Furthermore, the pituitary may also be affected by neoplasms such as cerebral lymphoma with peripheral involvement of the gland.90005 90004 Despite the foregoing, evaluation of anterior pituitary reserve in HIV infected patients by TSH or gonadotropin stimulation has demonstrated a normal response in nearly all patients. Suggesting that panhypopituitarism is rare in these patients. 90005 90004 GH deficiency does not appear to be common [1]. Posterior pituitary function may be altered in HIV patients with Hyponatremia occurring in up to 50% of inpatients and about 20% of outpatients with AIDS; two-thirds of these patients are clinically euvolemic with serum arginine vasopressin levels that are inappropriately high for the serum osmolality, consistent with the syndrome of inappropriate antidiuretic hormone secretion [10 — 12].The presence of Pneumocystis carinii pneumonia and / or treatment with trimethoprim appears to be the most significant risk factors for this complication. Furthermore, central diabetes insipidus has been reported in AIDS patients with herpetic meningoencephalitis. 90005 90002 3. Thyroid dysfunction 90003 90004 Although thyroid function tests are often abnormal in HIV patients, the prevalence of overt thyroid disorder is not significantly different from that of the general population [13]. Most asymptomatic patients with HIV infection have normal thyroid function.Some, however, exhibit increased serum total thyroxine (T 90100 4 90101) and triiodothyronine (T 90100 3 90101) concentrations. These increases are as a result of increases in serum thyroxine-binding globulin, the cause of which is unknown [14]. However, with progression of HIV infection and as the patients become more ill, serum T 90100 4 90101 and T 90100 3 90101 concentrations decline, as is obtained in most if not all chronically ill patients; serum thyrotropin concentrations however remain normal or slightly depressed.These changes are as a result of reduction in serum binding proteins, decreased extrathyroidal conversion of T 90100 4 90101 to T 90100 3 90101, and decreased secretion of thyrotropin [13], [14]. Cytokines may be involved in some of these; especially the reduction in the peripheral conversion of T4 to T3 [15]. 90005 90004 An increasing number of patients taking anti-HIV drugs are presenting with thyroid disorders as a result of improved immune function (immune reconstitution syndrome). Graves ‘disease is the commonest among immune reconstitution syndromes; others include Hashimoto’s thyroiditis and hypothyroidism.Autoimmune Thyroid Disease (AITD) occurs in 3% of women and 0.2% of men [13- 17]. Goddard proposed a staging of autoimmune manifestations related to HIV / AIDS (table 3) [18]. 90005 90008 90009 90009 90118 90010 90120 90012 Stage 90013 90014 90120 90012 Features 90013 90014 90015 90129 90010 90131 Stage I 90014 90131 Acute HIV infection, the immune system is intact and autoimmune diseases may develop. 90014 90015 90010 90131 Stage II 90014 90131 The quiescent period without overt manifestations of AIDS associated with a declining CD4 count indicative of some immunosuppression.Autoimmune diseases are not found. 90014 90015 90010 90131 Stage III 90014 90131 Immunosuppression with low CD4 count and the development of AIDS. CD8 T cells predominate and diseases such as psoriasis and diffuse immune lymphocytic syndrome (similar to Sjogren’s syndrome) may present or even be the initial manifestation of AIDS. No autoimmune diseases are found. 90014 90015 90010 90149 Stage IV 90014 90149 Restoration of immune competence following HAART. In this setting, there is a resurgence of autoimmune disorders.90014 90015 90050 90051 Table 3. 90052 90004 Stages of autoimmune manifestations in HIV / AIDS. 90005 90004 The prevalence of immune reconstitution Autoimmune Thyroid Disease (AITD) (Graves ‘disease, Hashimoto thyroiditis, and hypothyroidism) is about 3% for women and 0.2% for men. Patients with lower CD4 counts at baseline with greater increments in the CD4 counts following HAART are more likely to develop AITD. 90005 90004 Thyroid dysfunction in HIV-positive individuals can result from gland destruction by opportunistic pathogens such as Pneumocystis jirovecii which has been reported to cause a painful low uptake thyroiditis like picture with hyperthyroidism followed by hypothyroidism.Other opportunistic pathogens that could affect the thyroid gland in HIV infected individuals include Cryptococcus neoformans, Aspergillosis and cytomegaloviurs [19 — 23]. The gland may also be invaded by Kaposi Sracoma with resultant hypothyroidism [24]. 90005 90004 Overt Hypothyroidism should be treated with levothyroxine keeping in mind that drug interactions between levothyroxine and protease inhibitors have been reported, perhaps through the shared metabolic pathway of glucuronidation. In subclinical hypothyroidism however, the TSH level should be determined again within three months as the levels normalize within a year in up to 30% of affected patients.In cases of overt hyperthyroidism, it is paramount to establish whether it is as a result of Graves ‘disease, or thyroiditis and the appropriate therapy instituted. 90005 90002 4. Adrenal dysfunction 90003 90004 Biochemical evidence of adrenal insufficiency is relatively common in hospitalized AIDS patients occurring in almost a fifth of such patients however, only about 4% are clinically symptomatic patients [25]. Adrenal dysfunction may be suspected in HIV-infected patients with advanced stage of AIDS.High index of suspicion is required; subtle impairment of adrenal function is manifested as fatigue, hyponatremia or rarely with clinical symptoms of adrenal insufficiency. At autopsy, the adrenal gland shows evidence of both inflammation and necrosis 90168 1 90169, [26 — 28]. Adrenal secretion of aldosterone and adrenal androgens may also be impaired. In fact, there appears to be a shift from adrenal androgen and aldosterone production toward glucocorticoid production. However, the secretion of aldosterone in response to assumption of the upright posture and the administration of angiotensin II is normal.The mechanisms by which HIV might affect adrenal secretion appear to be dependent on effects of cytokines and other immunomodulatory substances on the hypothalamo-pituitary-adrenal axis [29 — 32]. The potential sites of immune modulation of this is shown in this figure 1. 90005 90004 Interleukin-1 is a likely candidate as either a direct or an indirect adrenal stimulator. Its production by macrophages is stimulated by tumor necrosis factor, and the production by macrophages of both interleukin-1 and tumor necrosis factor is stimulated by HIV infection [33].90005 90004 Interleukin-1 may affect the hypothalamus, pituitary, or adrenal glands in a variety of ways [29]. Interleukin-1 stimulates the release of corticotropin-releasing hormone from the hypothalamus into the portal circulation leading to the increases in corticotropin and consequently cortisol secretion. Furthermore, Interleukin-1 has been shown to directly stimulate cultured pituitary cells to release corticotropin. Cultured adrenocortical cells secrete more cortisol when cocultured with mononuclear cells most likely as a result of a response to the production of interleukin-1 by mononuclear cells [30 — 32].Interferon, another product of HIV-infected monocytes and macrophages, is also an immunomodulator of the hypothalamo-pituitary-adrenal axis [34]. 90005 90004 Both interleukin-1 and interferon thus have effects that could stimulate adrenal function. Conversely, adrenal function could be inhibited in patients with HIV infection as a result of polyclonal B-cell activation and the production of anti-adrenal-cell antibodies. The specific cellular or hormonal antigenic determinants and the pathogenetic importance of these antibodies are unclear.In addition to these mechanisms of adrenal dysfunction in patients with HIV infection, drugs which impair adrenal function directly such as Ketoconazole which inhibits adrenal steroidogenesis, Rifampicin, phenytoin, and opiates which accelerate the degradation of cortisol and therefore lower serum cortisol concentrations are frequently prescribed in HIV infected patients. Although the resulting need for increased cortisol secretion is easily met in normal subjects, it may not be so in patients with HIV infection.90005 90177 Figure 1. 90178 90004 Effects of cytokines on the Hypothalamo-pituitary-adrenal axis. 90005 90002 5. Glucocorticoids 90003 90004 The adrenal corticosteroids (Cortisol and Aldosterone), exert profound influences on many physiologic functions by virtue of their diverse roles in growth, development and maintenance of homeostasis [35]. The actions of these corticosteroids are mediated by intracellular receptor proteins, the glucocorticoid (GR) and mineralocorticoid (MR) receptors respectively.These receptors act as hormone-activated transcription factors which regulate the expression of the glucocorticoid and mineralocorticoid target genes respectively. The GR is ubiquitous and is found in virtually all human tissues and organs [1, 35]. 90005 90004 Glucocorticoids are essential to maintain the integrity of central nervous system and cardiovascular function, as well as the maintenance of metabolic and immune function. 90005 90004 Tissue hypersensitivity to glucocorticoids was recently hypothesized in patients with Human Immunodeficiency Virus type-1 infection via the accessory proteins Vpr and Tat which enhance GR transactivation [36].Since HIV-1 long terminal repeat (LTR) and glucocorticoid-responsive promoters use the same set of co-activators, these proteins may stimulate HIV-1-LTR and glucocorticoid-inducible genes concurrently. The former may directly stimulate viral proliferation, while the latter may indirectly enhance viral propagation by suppressing the host immune system through glucocorticoid mediated mechanisms. 90005 90002 6. Glucocorticoid hypersensitivity in AIDS 90003 90004 AIDS patients have several manifestations compatible with tissue hypersensitivity to glucocorticoids [37].Some of the manifestations include reduction of innate and cellular immunity mediated through T helper 1 cells with resultant reduction in the secretion of interleukin (IL) -2, IL-12 and interferon and increased secretion of IL-4. These changes are similar to what obtains when exogenous glucocorticoids are administered as well as in hypercortisolemic patients with endogenous Cushing’s syndrome. Furthermore, hippocampal atrophy similar to what is observed in individuals who exhibit hypercortisolism is seen in HIV infected patients especially in pediatric AIDS patients.Other features seen in HIV / AIDS patients that are similar to features of hypercortisolism include muscle wasting and myopathy, dyslipidemia and visceral obesity and insulin resistance. From the foregoing, it seems possible that some unknown factor (s) modulate tissue sensitivity to glucocorticoids in HIV infected patients. 90005 90004 The observed glucocorticoid hypersensitivity in HIV infected patients seem to preferentially affect the brain, fat cells, the liver, the musculoskeletal system and the immune system.It is noteworthy that the hypothalamo-pituitary-adrenal axis is not affected suggesting that appropriate negative feedback sensitivity to glucocorticoids is preserved. 90005 90004 There is evidence to suggest that glucocorticoid hypersensitivity in HIV / AIDS is mediated through one of the HIV-1 accessory proteins the virion-associated protein (Vpr). This is a 96 amino acid protein with multiple functions. This protein is known to act as a transcriptional activator of several viral promoters and as an enhancer of HIV-1 long terminal repeat promoter activated by Tat as well as enhances the replication of HIV-1 virus in lymphocyte- and monocyte-derived cell lines.Furthermore, the protein also increases the translocation of the HIV-1 pre-integration complex into the nucleus promoting efficient infection of non-dividing macrophages. 90005 90004 The protein circulates in HIV-1-infected individuals and has the capacity to penetrate cell membranes. This suggests that its effects have the potential to involve all cells including those not infected by HIV-1. It is indeed this protein that has been shown by Kino 90198 et al 90199 [36] to increase the tissue sensitivity to glucocorticoids by functioning as a coactivator of the GR on its responsive promoters.By inducing hypersensitivity to glucocorticoids, these proteins contribute to the proliferation of the virus indirectly by suppressing the host immune system. Extensive further clinical and basic investigations are crucial to examine the clinical importance of glucocorticoid hypersensitivity and to develop novel effective therapeutic approaches in AIDS. 90005 90004 Although the involvement of the adrenal gland is common in HIV patients, routine screening is not however recommended as adrenal insufficiency is a relatively rare complication of HIV infection.Its presence should however be considered, however, in those with disseminated cytomegalovirus infection or tuberculosis. It should also be suspected, in patients with otherwise unexplained symptoms and signs compatible with adrenal insufficiency, such as anorexia, nausea, weight loss, and fatigue, and especially in patients with more specific manifestations of adrenal insufficiency, such as postural hypotension, hyponatremia, or hyperkalemia. It is also reasonable to be concerned about adrenal reserve in patients who are about to undergo major stress, such as surgery.The simplest test is to measure the serum cortisol concentration in the morning, when it is highest in normal subjects. A concentration of 10 μg per deciliter (280 nmol per liter) or less suggests the presence of adrenal insufficiency. However, higher cortisol concentrations do not rule out the possibility of diminished adrenal reserve. If the basal serum cortisol concentration is low or the suspicion of adrenal insufficiency persists, provocative testing with corticotropin is indicated. Such testing involves measuring the serum cortisol concentration before and 30 and 60 minutes after the intravenous or intramuscular administration of 0.25 mg of cosyntropin. The cortisol concentration should increase by at least 7 μg per deciliter (196 nmol per liter) at 30 minutes and 11 μg per deciliter (308 nmol per liter) at 60 minutes. Alternatively, a normal response is a concentration twice the basal value at 60 minutes. Whether one considers the extent of a change in the cortisol concentration or the multiple of the basal value, the peak stimulated value should be 18 μg per deciliter (504 nmol per liter) or more for the response to be considered normal [48, 49] .Glucocorticoid therapy should be given only in cases of documented adrenal insufficiency or when there is a medical emergency in which the possibility of adrenal crisis can not be excluded. 90005 90002 7. Gonadal dysfunction in male 90003 90004 Male gonadal dysfunction is common among AIDS patients. With more than two-thirds of male patients with advanced HIV disease exhibit of loss of libido and up to one-third of them having erective dysfunction [38, 39]. The prevalence and severity of male gonadal dysfunction is directly proportional to disease severity.In advanced disease stages, biochemical hypogonadism is found in up to half of male AIDS patients. With the advent of HAART, the prevalence of male gonal dysfunction has reduced to about 20% among those receiving HAART [40]. Gonadal dysfunction in HIV / AIDS is usually attributable to secondary causes such as the effect of under nutrition, infection-inflammation and several drugs on gonadotropin production. Other secondary causes include the role of cytokines produced in response to systemic illness may impair the secretion of gonadotropin-releasing hormone or gonadotropin [41].Low levels of interleukin-1 enhance testicular steroidogenesis in vitro, whereas higher doses inhibit the binding of gonadotropin to Leydig cells and steroidogenesis by these cells. Ketoconazole used in the treatment of fungal infections in HIV / AIDS patients inhibits gonadal as well as adrenal steroid production and could therefore also contribute to the observed gonadal dysfunction. 90005 90004 Furthermore, hyperprolactinaemia and gynecomastia have been reported among HIV-infected patients [42].Prolactin has for long been known to be an immunostimulatory hormone and is also known to be elevated in other immunostimulatory states such as systemic lupus erythematosis (SLE). Similarly, prolactin receptors are found in T and B lymphocytes as well as monocytes [43], while lymphocytes are known to produce a prolactin like protein. The men with low serum testosterone concentrations may have inappropriately normal serum gonadotropin concentrations, suggesting involvement of the pituitary gland or hypothalamus however, there is neither CT scans nor autopsy data provide evidence of pituitary or hypothalamic disease.90005 90004 As sex hormone binding capacity increases in up to a third of HIV patients, the use of free testosterone assay is recommended for diagnosis. [38] Physiologic testosterone replacement that does not suppress endogenous gonadal function results in increased lean body mass, improved quality of life and reduction in depression. Standard therapy for hypogonadism has been intramuscular testosterone (enanthate or ciprionate esters) every 1-3 weeks to provide 100 mg per week. Alternate transdermal or oral routes for androgen administration are also available.Prostate-specific antigen level should be monitored in elderly patients receiving testosterone. 90005 90002 8. Gonadal dysfunction in female 90003 90004 Ovarian dysfunction among female AIDS patients is less common. Amenorrhoea is seen in about a quarter of women during stress of illness; while failure of ovulation is seen among half of the female patients with low CD4 counts [44]. Early menopause has been seen in up to 8% of HIV-infected female patients. Androgen deficiency has been reported especially in women with significant weight loss.The reasons for the above observations are not clear, but could be as a result of intra-adrenal shunting toward cortisol production from androgen synthesis. Human chorionic gonadotropin levels suggest intact ovarian androgen production. Delivery of low doses of testosterone using transdermal patches improves functional capacity without hirsuitism or virilisation but does not increase lean body mass [38]. 90005 90002 9. Glucose homeostasis in HIV / AIDS 90003 90004 Normal glucose metabolism is largely dependent on normal insulin secretion, insulin sensitivity and to a lesser extent on the influences of other hormones and cytokines.Before the advent of highly active anti-retroviral therapy (HAART), HIV infection on its own was thought to be protective against the development of diabetes mellitus 90168 1 90169, this may be due to the following observations in clinically stable, symptomatic HIV-infected patients. These individuals have been shown to have higher rates of insulin clearance and increased sensitivity of peripheral tissues to insulin as well as an increase in noninsulin-mediated glucose uptake. The increase in glucose uptake is predominantly accounted for by an increase in non-oxidative glucose disposal.90005 90004 Pancreatic abnormalities are common in AIDS patients as a result of opportunistic infections and malignancies 90168 1 90169. However, the majority of these lesions are not extensive enough to cause clinically significant pancreatic dysfunction. Clinically significant pancreatic dysfunction is usually as a result of therapeutic interventions; noteworthy in this regard is Pentamidine [45], which is used in the management of Pneumocystis carinii and may cause pancreatic β-cell toxicity with resultant hypoglycaemia in the acute phase and some of these patients may later develop diabetes mellitus.90005 90004 With the advent of HAART however, a new dysmetabolic syndrome with substantially increased risk for cardiovascular events emerged [46]. This syndrome has variable expressibility; and includes insulin resistance, visceral adiposity, peripheral lipodystrophy, dyslipidaemia and glucose intolerance. Several studies have demonstrated an increased risk of diabetes among HIV infected individual on HAART especially when protease inhibitors (PIs) are included in the regimen. Among HIV infected minority patients in the USA for example, the prevalence of diabetes after three years of PI therapy was 12%, compared to none among those not receiving PI’s 90168 4 90169.However, although PI’s are the most frequent agents associated with metabolic complication, there are evidences to suggest that virtually all classes of agents used in ART has the potential to cause metabolic derangements. Although the mechanism by which ART drugs induce these metabolic changes are not fully clear; it has been shown that indinavir, a PI dramatically inhibits glucose uptake in a dose dependent manner in adipocytes by selectively inhibiting the Glut-4 transporter function [47]. Furthermore, there is evidence at least in laboratory studies to show that indinavir down regulates the peroxisome proliferator-activated receptor -γ (PPAγ) receptor in adipocytes [48].Obviously some genetic predisposition could explain why not all patients on PI’s develop diabetes, or any of the other metabolic complications. 90005 90002 10. Bone mineral dysfunction 90003 90004 Both osteoporosis and osteopenia are common among AIDS patients. Reduced bone mineral density is seen in almost three quarter of HIV-infected patients compared to about 30% in HIV-negative individuals of similar age [49]. Reduced vertebral bone density is associated with visceral adiposity among HIV-infected patients.Similarly, reduced bone density also occurs in HIV-infected children receiving HAART with maximum reduction seen among those with lipodystrophy. Several factors are thought to be responsible for the observed effects on the skeleton. The effects of low GH and IGF1, hypogonadism and excess visceral adiposity are possible factors as they have been found to correlate significantly with vertebral bone density [50 — 52]. Protease Inhibitors are also known to induce relative vitamin D deficiency and may also act as an additive factor.90005 90002 11. Calcium and vitamin D balance 90003 90004 Hypocalcemia is common in HIV infected patients occurring in more than 5% of them [53]. It appears the level of calcium has an inverse relationship with the stage of the disease and its severity. Factors responsible for hypocalcaemia in these patients include vitamin D deficiency and reduced parathyroid hormone (PTH) level. The cause of the relatively reduced PTH is not known but may be as a result of the effects of cytokines; and presence of hypomagnesemia which is relatively common among HIV infected patients especially those with chronic diarhoea.On the other hand, the cause of Vitamin D deficiency is multifactorial in the setting of HIV / AIDS and may include malabsorption, decreased hydroxylation as a result of the effects of protease inhibitors. Furthermore, several therapeutic agents such as foscarnet, pentamidine, and ketoconazole, may affect calcium homeostasis [53]. 90005 90004 Hypercalcemia is uncommon in AIDS. When present it is likely to be due to infectious, malignant, or granulomatous processes [54 — 55]. Patients with lymphoma who have hypercalcemia typically have increased serum 1,25-dihydroxyvitamin D concentrations, because the tumors contain vitamin D 1-hydroxylase and therefore convert 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D.Cultured lymphoma cells infected with HIV have the same synthetic activity. Human T-cell lymphotropic virus Type I (HTLV-I), a retrovirus linked to T-cell leukemia and lymphoma may be associated with hypercalcemia. Increased bone resorption in this syndrome may be due to lymphokines such as interleukin-2 or to parathyroid hormone-related protein. A HTLV-I gene product, 90198 tax 90199, has been implicated in the activation of the parathyroid hormone-related protein gene. Serum concentrations of parathyroid hormone and 1,25-dihydroxyvitamin D are not elevated in HTLV-I-related hypercalcemia.90005 90002 12. AID wasting syndrome 90003 90004 Wasting is an age-old terminal event of AIDS, even with the advent of HAART, wasting remains common affecting more than one-third of patients [57]. Unfortunately, weight loss is a significant predictor of mortality in HIV infection. Those with a body mass index (BMI) of less than 18.4 kg / M 90168 2 90169 are at 2.2-fold increased risk of mortality, while those with a BMI less than 16 kg / M 90168 2 90169 are at 4.4-fold increased risk of mortality [58].90005 90004 Currently, AIDS wasting syndrome is defined as body weight less than 90% of ideal weight or weight loss of more than 10% of body weight over 3 months. The condition is characterised by a disproportionate loss of lean body mass with a relative sparing of body fat as the disease progresses this is associated with muscle wasting, weakness, increased resting energy expenditure and hypertriglyceridemia. The exact mechanisms involved in the aetiology of this condition are not clear. However, the roles of Cytokine related increased energy expenditure and decreased appetite, diarrhoea, malabsorption and hypogonadism are likely mechanisms behind such wasting [59, 60].90005 90004 Management of this condition include optimal antiretroviral therapy and adequate nutrition. Testosterone (intramuscular / transdermal) has been successfully used to increase lean body mass in men with this syndrome, whereas it has also been shown to be safe and well tolerated in women. A number of agents like anabolic steroids (oxandrolone, nandrolone), megesrtol acetate, thalidomide, human chorionic gonadotropin, pentoxyfiline, amino acid mixtures and omega 3 fatty acids have been tried in this setting with variable efficacy but potential side effects.Only testosterone administration has proved useful to increase lean body mass, especially in conjunction with progressive resistance training. Administration of supraphysiologic doses of growth hormone is currently reserved for severe wasting refractory to other treatments. 90005 90002 13. HIV lipodystrophy syndrome 90003 90004 HIV lipodystrophy syndrome is associated with metabolic derangements, changes in body composition and abnormal fat distribution. It has been most widely recognized since the era of HAART but can also be seen in antiretroviral-naïve patients [61].It is characterized by phenotypic changes similar to those observed in Cushing’s syndrome, such as like truncal obesity, buffalo hump, peripheral fat loss, atrophy of facial fat and breast enlargement in women. Considering some physical similarities to Cushing’s syndrome, it has been termed as «a pseudo-Cushing’s syndrome» though no other specific stigmata of Cushing’s syndrome (proximal muscle weakness, bruising and facial plethora) nor biochemical parameters are associated with this syndrome. Normal cortisol level with its normal diurnal variation and adequate suppressibility to dexamethasone are also seen in HIV lipodystrophy syndrome.However, it is very often associated with insulin resistance, hyperglycemia, and hypertriglyceridemia. In particular, dyslipidemia and diabetes mellitus are increasingly common among patients receiving HAART. management consist of exercise and lifestyle modification, switching to less-toxic NRTIs or PIs, fenofibrates to decrease serum triglyceride level, and use of insulin sensitizers like metformin to reduce visceral fat and thiazolidinediones to improve subcutaneous fat loss. Testosterone and anabolic steroids have no effect in reducing visceral fat in this syndrome.90005 90002 14. Conclusion 90003 90004 Although HIV endocrinopathy is common, overt glandular failure is a rare clinical entity. HIV infection, acting by a number of mechanisms, may be responsible for subtle clinical and not-so-subtle biochemical abnormalities. Drug-induced endocrine toxicity is important cause of endocrinopathy in HIV infected patients. 90005.90000 HIV signs and symptoms in women 90001 90002 HIV can affect anyone, and some symptoms may be different in women. 90003 90002 In late 2014 року, the Centers for Disease Control and Prevention (CDC) estimates, more than 250,000 women in the United States were living with HIV. 90003 90002 Below, we describe HIV symptoms in women, how doctors diagnose the condition and what treatment options are available. 90003 90008 90009 Image credit: Stephen Kelly, 2018 90010 90002 Within a few weeks of contracting HIV, the body goes through seroconversion, a period in which the virus rapidly multiplies.90003 90002 During seroconversion, the virus can cause a flu-like illness called an acute HIV infection. 90003 90002 After this initial period, further symptoms can develop, especially if a person does not receive treatment. 90003 90002 Symptoms of HIV in women can include: 90003 90019 Flu-like symptoms 90020 90002 After contracting HIV, the immune system mounts a response to the virus. 90003 90002 Symptoms may include: 90003 90002 The symptoms above usually appear 2-6 weeks after contracting HIV, and they can last anywhere from a week to a month.90003 90002 These symptoms can resemble those of a cold or flu, so a person may not initially associate them with HIV. 90003 90002 Many symptoms of an acute HIV infection are common in males and females. However, some women may experience other symptoms, including: 90003 90019 Swollen lymph nodes 90020 90002 Swollen lymph nodes can be one of the earliest symptoms of HIV, after those of an acute infection. 90003 90002 Following an acute HIV infection, the virus continues to multiply, but at a slower rate.A person may or may not have symptoms. 90003 90002 Treatment can slow or stop the virus ‘progression. Even without treatment, some people experience no additional symptoms for up to a decade after the initial infection. 90003 90002 The neck may feel swollen just under the jaw and behind the ears. The swelling can cause trouble swallowing, and it may last anywhere from a few days to months. 90003 90019 Vaginal yeast infections 90020 90002 HIV can increase the risk of developing vaginal yeast infections.Symptoms of these infections include: 90003 90045 90046 burning in and around the vagina and vulva 90047 90046 pain during sex 90047 90046 painful urination 90047 90046 thick, white vaginal discharge 90047 90054 90002 While almost all women have yeast infections from time to time, HIV can cause these infections to occur more frequently. 90003 90002 When a person has HIV, their immune system devotes a lot of energy to fighting the virus. As a result, their body is not as equipped to combat other infections.90003 90019 Rapid weight loss 90020 90002 If a person is not receiving HIV treatment, the virus can cause nausea, diarrhea, poor food absorption, and appetite loss. 90003 90002 Each of these issues can cause a person to lose weight quickly. 90003 90019 Changes in mood 90020 90002 Sometimes, HIV progression can cause mood changes neurological disorders in women. 90003 90002 This may involve depression, which can cause feelings of hopelessness and intense sadness. People may also experience stress and memory loss.90003 90019 Skin changes 90020 90002 HIV can cause unusual spots to form on the skin. They may be red, pink, brown, or purple. These spots may appear inside the mouth, eyelids, or nose. 90003 90002 Sores can also develop on the mouth, genitals, or anus. A list of various skin rashes can be found here. 90003 90019 Menstrual changes 90020 90002 Some women with HIV notice lighter or heavier periods. Also, if a person is experiencing rapid weight loss, they may begin to miss periods. 90003 90002 In addition, hormonal fluctuations can cause menstrual symptoms, such as cramps, breast tenderness, and fatigue, to change or get worse.90003 Share on PinterestDoctors recommend HIV testing for everyone aged 13-64 as part of routine care. 90002 The CDC recommend that everyone ages 13-64 get tested for HIV at least once as part of routine care. They also advise every pregnant woman to take an HIV test. 90003 90002 Some women have a higher risk of contracting HIV. Risk factors include: 90003 90002 If a person has any of the above risk factors, they should talk to their doctor about HIV testing. The doctor should also advise about how often to take a test.90003 90002 The CDC estimate that, of all the women with HIV in the U.S. in 2014 року, 88 percent had received a diagnosis. 90003 90002 Early diagnosis is crucial, and many therapies can help a person manage HIV without complications. 90003 90002 Different types of tests can help a doctor diagnose HIV. Some tests can not detect the virus in the early stages. 90003 90002 HIV tests include: 90003 90045 90046 90099 Antibody tests 90100: These detect the presence of HIV antibodies, or immune system proteins, in blood or saliva samples.Rapid and at-home tests are usually antibody tests. They can not detect HIV at an early stage. 90047 90046 90099 Antigen / antibody tests 90100: These detect HIV antibodies and antigens, or viral components, in the blood. Antigen / antibody tests also can not detect HIV at an early stage 90047 90046 90099 Nucleic acid tests 90100: These look for the presence of HIV’s genetic material in the blood, and they can detect HIV at an early stage. 90047 90054 90002 Anyone who may have contracted the virus and who has early symptoms may wish to speak to a doctor about a nucleic acid test.90003 90002 While there is currently no cure for HIV, doctors can prescribe medications that either stop the virus from replicating or reduce the rate at which the virus multiplies. 90003 90002 These medicines are called antiretroviral therapies, and there are several different types. 90003 90002 A person may need to take between one and three medications a day, depending on their needs. 90003 90002 Ideally, if a person takes antiretroviral therapies as instructed, the virus will stop replicating, and the immune system can fight off those that remain.90003 90002 Levels of the virus may diminish until they are no longer detectable. However, HIV remains in the body, and if a person stopped taking their medications, the virus could start to replicate again. 90003 90002 HIV symptoms can resemble those of other illnesses. Initial symptoms may be similar to those of the flu, for example. 90003 90002 Women may also experience other symptoms later on, such as frequent vaginal yeast infections. 90003 90002 Anyone who thinks that they may have HIV should speak to a doctor about testing.90003 90002 Thanks to innovations in treatment, people can manage HIV much like any other chronic condition. This can help prevent later-stage symptoms. 90003.90000 PPT — Clinical Manifestations and Treatment of HIV PowerPoint Presentation 90001 90002 90003 90004 Clinical Manifestations and Treatment of HIV 90005 Ronald Mitsuyasu, MD Professor of Medicine Director, UCLA Center for Clinical AIDS Research and Education (CARE Center) 90006 90007 90008 90003 90004 The Natural History of HIV Infection 90005 Pantaleo G, et al. N Engl J Med 1993; 328; 327. 90006 90007 90014 90003 90004 Clinical Manifestations of HIV 90005 • Early signs and symptoms • Oral manifestations • Malignancies • Opportunistic Infections • Neuro-psychiatric illnesses • Women and HIV = Not in today’s presentation, 90006 90007 90020 90003 90004 Signs and Symptoms 90005 90006 90007 90026 90003 90004 CDC Stage of HIV Disease 90005 • Stage I Acute HIV infection • Stage II Asymptomatic HIV • Stage III Early Symptomatic HIV • Stage IV Late Symptomatic HIV • A Constitutional Disease • B Neurological Disease • C Secondary Infections • C1 AIDS defining • C2 Other infections • D Secondary Cancers • E Other Conditions 90006 90007 90032 90003 90004 Acute Retroviral Syndrome 90005 • Fever 96% • Lymphadenopathy 74% • Pharyngitis 70% • Rash 70% • Myalgia / Arthraligia 54% • Diarrhea 32% • Headaches 32% • Nausea / Vomiting 27% • Hepatomegaly 14% • Weight Loss 13% • Neurologic symptoms 12% 90006 9000 7 90038 90003 90004 Oral Manifestations of HIV 90005 90006 90007 90044 90003 90004 No disease 90005 Angular cheilitis Recurrent oral ulceration Persistent oral candidiasis Oral hairy leukoplakia Acute necrotizing ulcerative stomatitis, gingivitis, periodontitis Chronic (> 1 mo) orolabial HSV Kaposi’s sarcoma Non-Hodgkin’s lymphoma No disease Angular Cheilitis Linear gingival erythema, extensive warts Recurrent oral ulcerations, parotid enlarge Persistent oral candidiasis (after 8ws) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis or periodontitis Chronic (> 1 mo) orolabial HSV Kaposi’s sarcoma Non-Hodgkin’s lymphoma WHO Clinical Staging of Oral Manifestations of HIV Stage Adults and Adolescents (> 15 yo) Children <15 yo 1 2 3 4 WHO, Classification of HIV, 2007 http: // www.who. int / hiv / pub / guidelines / HIVstaging150307.pdf 90006 90007 90050 90003 90004 HIV-related Oral Lesions 90005 • Infections • Fungal, Viral, Bacterial • Neoplasms • Kaposi's Sarcoma, Non-Hodgkin's Lymphoma • Other • Aphthous-like Ulcers, Lichenoid or Drug Reactions, Salivary Gland Disease 90006 90007 90056 90003 90004 Oral CandidiasisClinical Types 90005 ErythematousPseudomembranousAngular Cheilitis DHS / HIV / PP 90006 90007 90062 90003 90004 Hairy Leukoplakia 90005 • Treatment and Management: • Generally does not require treatment • Antiviral treatment and topical podophyllum resin have been used to treat - the result is temporary • May wax and wane without treatment 90006 90007 90068 90003 90004 Herpes simplex infection 90005 Cytomegalovirus infection Aphthous ulcers Histoplasmosis HPV lesions Lymphoma Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP) Necrotizing stomatitis (NS) Oral Ulcers 90006 90007 90074 90003 90004 Aphthous Lesio nsClinical Types 90005 Minor (Lip) Minor (Tongue) Major DHS / HIV / PP 90006 90007 90080 90003 90004 Oral Aphthous LesionsTreatment Options 90005 • Topical Therapy- Topical Corticosteroids • Intralesional- Triamcinolone: ​​40 mg / ml (0.5 ml-1.0 ml injected bid) • Systemic Therapy- Prednisone: 0.5-1.0 mg / kg qd x 7-10d, then taper- Thalidomide: 200 mg PO qd DHS / HIV / PP 90006 90007 90086 90003 90004 Lesions Caused By Human Papilloma Virus (HPV) 90005 • Appearance: exophytic, papillary, oral mucosal lesions • Several different types of HPV have been reported to cause lesions • May be multiple • Often difficult to treat due to a high risk of recurrence 90006 90007 90092 90003 90004 Kaposi's Sarcoma 90005 • Appearance: Oral lesions appear as reddish purple, raised or flat • Size ranges from small to extensive • Behavior is unpredictable • Definitive diagnosis: biopsy and histologic examination • No curative therapy - antiretroviral therapy, radiation treatment, chemotherapy and sclerosing agents have been, used to control oral lesions 90006 90007 90098 90003 90004 cancers in HIV 90005 90006 90007 90104 90003 90004 Number of people living with AIDS, AIDS-defining cancers, 90005 non-AIDS-defining cancers , And all cancers in the USA during 1991-2005.Cancer Incidences in HIV in USA Shiels M S et al. J Natl Cancer Inst 2011 року; 103: 753-762 90006 90007 90110 90003 90004 Categorizing Cancers in PWHA 90005 AIDS Defining Cancer (decreasing) KS NHL (BL, CNS, DLCBL) Cervical Cancer (added in 1993) Non AIDS defining Cancers (increasing) Anal Cancer Lung Cancer Hodgkin Lymphoma Liver Cancer Elevated risk but rare Merkel Carcinoma Leiomyosarcoma Salivary gland LEC Unchanged risk Breast Colorectal Prostate Follicular lymphoma 90006 90007 90116 90003 90004 Cancers in HIV Disease 90005 AIDS-DefiningVirus Kaposi's Sarcoma HHV-8 Non-Hodgkin's Lymphoma EBV, HHV -8 (systemic and CNS) Invasive Cervical Carcinoma HPV Non-AIDS Defining Anal Cancer HPV Hodgkin's Disease EBV Leiomyosarcoma (pediatric) EBV Squamous Carcinoma (oral) HPV Merkel cell Carcinoma MCV Hepatoma HBV, HCV 90006 90007 90122 90003 90004 Breakdown of causes of death : France 2005 90005 AIDS Cancer Hepatitis C CVD Su icide Non-AIDS infection Accident Hepatitis B Liver disease OD / drug abuse neurologic renal pulmonary digestive iatrogenic metabolic psychiatric other unknown N = 937 deaths Lewden JAIDS 2008, 48: 590-9 Percent Hessamfar-Bonarek Int.J. Epid 2010 року; 39: 135-146 90006 90007 90128 90003 90004 Non-AIDS Defining CancersNADC 90005 90006 90007 90134 90003 90004 Non AIDS-defining CancersEmerging Epidemiologic Features 90005 Engels EA, Int J Cancer. 2008; 123: 187-194 90006 90007 90140 90003 90004 Factors Contributing to the Increasein Cancer cases in HIV 90005 4-fold increase in HIV / AIDS Population Greater and earlier start to smoking in HIV Rising proportion of HIV pts> 50 yo Cancer incidence increases with age Increase in some CA incidence rate among HIV Lung (3X), anal (29X), liver (3X), HL (11X) Suggests may be additional risk from HIV 90006 90007 90146 90003 90004 NADC incidence and Mortality 90005 Retrospective survey of Kaiser Permanente, N.and S. California; 22,081 HIV +, 230,069 HIV- matched by age, sex, clinic and initial yr of F / U 5-yr survival for incident prostate, anal, lung, colorectal cancers or Hodgkin lymphoma. All cause mortality rates and mortality hazard ratios Earlier mean age at dx in HIV + for anal, lung and colorectal, but not for prostate or HL HIV + dx at higher stage for lung and HL HIV + reduced survival for HL, lung and prostate, but not for anal and colorectal Silverberg M et al. 19th CROI, Seattle, 2012 abs 903.90006 90007 90152 90003 90004 NADC Mortality HIV + vs HIV- 90005 Lung 1.7 (1.3-2.2) Hodgkin Lymphoma HR 3.0 (1.3-10.8) Prostate 2.2 (1.2-4.3) Anal 1.7 (0.6-5.4) Colorectal 1.6 (0.8-3.1) Silverberg M et al. 19th CROI, Seattle, 2012 abs 903. 90006 90007 90158 90003 90004 Pathogenesis of Cancer in HIV 90005 Many are virally-induced cancers, but not all Immune activation, inflammation and decreased immune surveillance HIV may activate cellular genes or proto-oncogenes or inhibit tumor suppressor genes HIV induces genetic instability (e.g 6 fold higher number of MA in HIV lung CA over non-HIV) 1 Increase susceptibility to effects of carcinogens Endothelial abnormalities may allow for cancer development Population differences based on genetics and exposure to carcinogens Wistuba Il, Pathogenesis of NADC: a review. AIDS Pt Care 1999; 13: 415-26 90006 90007 90164 90003 90004 Lymphomas 90005 90006 90007 90170 90003 90004 Pathology of AIDS-RelatedNon-Hodgkin’s Lymphoma 90005 Small noncleaved-cell lymphoma Burkitt’s lymphoma and Burkitt-like lymphoma Immunoblastic lymphoma (primary CNS) Diffuse large-cell lymphoma (90% CD20 +) Large noncleaved-cell lymphoma CD30 + anaplastic large B-cell lymphoma Plasmablastic lymphoma Advanced stage (> 75% III or IV) Extranodal involvement Central nervous system, liver, bone marrow, gastrointestinal Tirelli U, et al .AIDS. 2000; 14: 1675-1688. 90006 90007 90176 90003 90004 AIDS-related Lymphoma Experience Suggests Cancer Treatment 90005 Outcome Can be Equivalent to General Population Besson et al. Blood. 2001; 98: 2339-2344 Little et al Blood. 2003; 101: 4653-4659 Sparano et al. Blood, 2010 року; 115: 3008-16 90006 90007 90182 90003 90004 Cancer Screening in HIV 90005 90006 90007 90188 90003 90004 ACS, NCI and USPSTF Cancer Screening Guidelines 90005 Cervical CA — begin within 3 yrs of 1st intercourse or 21 yo and q 1 2 yrs.If 30-70 and 3 normal Paps q3 yrs Prostate CA — discuss with MD at 50. DRE yearly and individualized PSA testing Breast CA — clinical breast exam q 3 yr 20-30, yearly at 40, yearly mammogram start age 50 Colon CA — flex sig q 5yrs or colon q 10 yrs and FOBT yearly Others — periodic health exams after age 20, with health counseling and oral, skin, lymph nodes, testes, ovaries and thyroid exam Other tests based on family history, other known cancer risk exposures or known risk factors 90006 90007 90194 90003 90004 HIV Patient Screening 90005 Routine screening for HIV patients seems to be done LESS frequently than age-appropriate SOC screening for breast (67% vs 79%) and colon (56% vs 77.8%) and prostate biopsies Preston-Martin. Prev Med 2002; 34: 386-92 Reinhold JP. Am J Gastroenterol 2005; 100: 1805-12 Hsiao W, Science World J 2009 року; 9: 102-8 Concerns about higher false positive rate in HIV (eg, NLST found reduction in lung cancer mortality (20%) in older cigarette smokers with CT) but also high false positive rates, which may be true in HIV as well 90006 90007 90200 90003 90004 Why is anogenital cancer important? 90005 Cervical cancer is the most common cancer in women worldwide and anal cancer is as common in MSM (75 / 100,000) as cervical cancer in unscreened populations of women (50-150 / 100,000 person-yr) Anal cancer particularly common in HIV + MSM Anal cancer occurs in women as well Anal cancer is one of several cancers whose incidence in the HAART era is increasing, not decreasing 90006 90007 90206 90003 90004 Screening for cervical and anal dysplasia 90005 No USA national or international guideline for anal screening other than NYS DOH anal Pap screening guidelines.Many HIV groups recommend yearly cervical and anal PAP, with colposcopy and / or HRA and biopsy of any suspicious lesions and q 6m F / U for those with abnormalities noted Many cervical cancer screen and treat program now operating in resource-limited settings Chiao EY et al. Clin Infect Dis 2006; 43: 223-33 Goldie SJ et al. JAMA 1999; 282: 1822-9 90006 90007 90212 90003 90004 Cancer Prevention 90005 Smoking Cessation — Highest priority Varenicline not hepatic met and no ART drug interaction expected Hepatitis B and HPV vaccination Treat active Hepatitis C Yearly cervical and anal Paps — Gyn and HRA Advise sun screen and avoid overexposure Maintain high index of suspicion for cancer Complete family history for malignancies Breast, prostate and colon screening as per guidelines for general population CT Lung and liver ultrasound controversial Treat all HIV patients with HAART 90006 90007 90218 90003 90004 Summary 90005 As HIV population ages with persistent immune abnormalities, cancers will increase in number The risk of NADC is high with lung, anal, liver and HL accounting for most of this increase.The risk of colon, breast and prostate cancers not elevated in HIV. HL occurs at older age, but may reflect lack of younger age peak, as all cases in HIV are EBV + As a minimum, we should conduct age / gender appropriate screening for cancer. Counsel patients on ways to reduce cancer risks Only through prospective clinical trials research can prevention strategies and new treatments be effectively evaluated 90006 90007 90224 90003 90004 Thank You 90005 For information on AMC clinical trials see: http: // www.aidscancer.org For information on NCI programs in HIV cancer see: http://www.cancer.gov/cancertopics/types/AIDS To refer for AMC clinical trials in LA, call UCLA CARE Center 310-557-1891 ask for Maricela Gonzalez or page / email Dr. Mitsuyasu, 310-825-6301. 90006 90007 90230 90003 90004 Use of Antiretroviral Therapy 90005 90006 90007 90236 90003 90004 Overview 90005 • Benefits and limitations of HAART • When to start • What to start with • Simplified drug regimens and treatment adherence • When to change therapy • Second line therapies 90006 90007 90242 90003 90004 Benefits of ART 90005 • Prevention of mother to child transmission • Post exposure prophylaxis (PEP) • Secondary prevention of HIV transmission • Primary prevention (PrEP) • Clinical management of patients with HIV • Reduces HIV replication • Increase or maintain CD4 numbers • Maintain «less fit» mutated HIV 90006 90007 90248 90003 90004 Current antiretroviral targets 90005 Fusion Inhibitor Enfuvirtide Entry Inhibitors CCR5, MRV Viral protease Inhibitors RNA RNA Proteins Reversetranscriptase Inhibitors SQV RTV IDV NFV APV LPV FOS ATZ TPV DRV RT RNA RNA ZDV, ddI, ddC, d4T, 3TC, ABC, TDF, FTC DLV, NVP, EFV, ETV RPV DNA RT DNA Integrase Raltegravir Elvitegravi r DNA Provirus 90006 90007 90254 90003 90004 Antiretroviral Drugs 2013 90005 Nucleoside analogues zidovudine (AZT, ZDV) didanosine (ddI) zalcitabine (ddC) stavudine (d4T) lamivudine (3TC) abacavir (ABC) emtricitabine (FTC) Nucleotide analogue tenofovir (TFV) Non-nucleoside analogues nevirapine (NVP) delavirdine (DLV) efavirenz (EFV) etravirine (ETV) rilpivirine (RPV) Protease Inhibitors (10) saquinavir (SQV) ritonavir (RTV) indinavir (IDV) nelfinavir (NFV) amprenavir (APV) lopinavir / r (LPV / r) fosamprenavir (FPV) atazanavir (ATV) tipranavir (TPV) darunavir (DRV) dolutegravir (DTG) Reverse Transcriptase Inhibitors (13) • Integrase Inhibitor (2) • raltegravir (RAL) • elvitegravir (ELV) • Fusion Inhibitor • fuzeon (T20) • Entry Inhibitor (CCR5) • maraviroc (MVC) 90006 90007 Load More….90000 HIV and Women’s Health Issues 90001 90002 How Does HIV Affect Women Differently? 90003 90004 HIV may cause some health problems that are unique to women, such as: 90005 90006 90007 Gynecological health issues 90008 90007 Increased risk of cervical cancer 90008 90007 Increased risk of heart disease 90008 90007 HIV medicine side effects and drug interactions 90008 90007 Aging- related issues 90008 90017 90004 Pregnancy and birth control also require careful management with a health care provider.90005 90004 The good news is that women who take HIV medicine (called antiretroviral therapy or ART) daily as prescribed and get and keep an undetectable viral load can stay healthy and have effectively no risk of transmitting HIV to an HIV-negative partner through sex. 90005 90002 Gynecological Health Issues and HIV 90003 90004 Gynecological problems are common among women living with HIV. Some of the issues women may experience are: 90005 90006 90007 90028 Problems related to sexually transmitted diseases (STDs) 90029 -Some STDS, like genital herpes, pelvic inflammatory disease (PID), and chancroid can happen more often and be more severe and / or harder to treat in women living with HIV than in HIV-negative women.STD screening and treatment is important for the health of a woman living with HIV and because having HIV and other STDs may increase the risk of HIV transmission to sexual partners. 90008 90007 90028 Vaginal yeast infections 90029 -In women living with HIV, vaginal yeast infections can occur more frequently and be harder to treat. Recurring vaginal yeast infections (those that happen at least four times a year) can happen more often in women with advanced HIV or AIDS. 90008 90007 90028 Bacterial vaginosis (BV) 90029 -BV is a condition caused by changes in the amount of certain types of bacteria found in the vagina.BV is more common in women living with HIV and may be harder to treat. 90008 90007 90028 Menstrual cycle problems 90029 -Women living with HIV may experience missed periods, lighter or heavier bleeding, or more severe premenstrual syndrome. 90008 90017 90004 Treatment is available for these health conditions. Talk to your health care team about treatment options that are right for you. 90005 90002 Cervical Cancer and HIV 90003 90004 Women with HIV have a higher risk of cervical cancer. It is important that they be screened regularly for this disease.90005 90004 Cervical cancer is cancer that starts in the cervix, the lower, narrow part of the uterus (the womb). It is almost always caused by human papillomavirus (HPV) infection. 90005 90004 The types of HPV that cause cervical cancer are more common in women with HIV. For this reason, women with HIV need to get regular Pap tests to help find changing cervical cells before they turn into cancer. Talk to your health care provider about the Pap test schedule that is right for you. In addition, the HPV vaccine is recommended for women (and men) with HIV infection through age 26.90005 90004 Cervical cancer is an AIDS-defining cancer. That means that a diagnosis of cervical cancer marks the point at which a person’s HIV infection has progressed to AIDS. 90005 90002 HIV Medicine Side Effects and Drug Interactions 90003 90004 HIV medicine works as well for women as it does for men. However, some medicines can cause different side effects in women than men. For example: 90005 90006 90007 90028 Nevirapine side effects 90029 -Studies have linked the HIV medicine nevirapine (also called Viramune or NVP) to a higher risk of rashes and liver problems for women with higher CD4 counts.90008 90007 90028 Ritonavir side effects 90029 -The HIV medicine ritonavir (also called Norvir or RTV) may cause more nausea and vomiting in women. It is sometimes prescribed to help other HIV medicines work better. 90008 90017 90004 HIV medicines can also put women at higher risk than men of getting fat buildup throughout their bodies or of having pancreas problems. 90005 90004 In addition, HIV medicines can interact with other drugs, which can harm you or make your HIV medicines less effective.These include: 90005 90006 90007 Prescribed medications 90008 90007 Over-the-counter medicines 90008 90007 Recreational drugs and alcohol 90008 90007 Herbal remedies 90008 90017 90004 If you are taking HIV medicines and have problems with any side effects or questions about drug interactions, talk to your health care provider or pharmacist to find solutions that work for you. Do NOT cut down on, skip, or stop taking your HIV medicines unless your provider tells you to. 90005 90002 Women’s Aging and HIV 90003 90004 Thanks to effective HIV treatment, women with HIV are living longer lives.That also means that as they age, they face the same health problems that many other older women do, such as heart disease, diabetes, high blood pressure, arthritis, and some cancers. 90005 90004 Women with HIV also may face also other health concerns as they age. These include: 90005 90006 90007 90028 Menopause 90029 -Women with HIV may enter menopause younger or have more severe hot flashes than women who do not have HIV. Researchers also think the drop in the female hormone estrogen after menopause may affect women’s CD4 counts.90008 90007 90028 Osteoporosis 90029 -Osteoporosis is a disease that causes bones to become weak and easy to break. It is a concern for all older women, but especially for women with HIV. Bone loss occurs faster in women (and men) living with HIV than in people who do not have HIV. Some HIV medicines may also increase the risk of osteoporosis. 90008 90017 90004 If you have questions about symptoms of the menopause or about osteoporosis, talk to your health care team. 90005 90002 Heart Disease and HIV 90003 90004 HIV-related heart disease is a leading cause of death among people living with HIV-even when they are on consistent, effective HIV treatment.90005 90004 The risk of heart attack is especially a concern for women. Women living with HIV are three times more likely to have a heart attack than women without HIV. 90005 90004 Research is underway to learn how factors unique to women with HIV affect heart disease risk and what to do about it. 90005 90002 Pregnancy and HIV 90003 90004 Women with HIV can have healthy pregnancies. But some may need to switch HIV medications. Talk with your provider if you are thinking of planning a pregnancy, including about how to prevent transmission if your partner is HIV-negative.90005 90004 In addition, women with HIV can pass the virus to their baby during pregnancy, childbirth, or breastfeeding. The good news is that there are ways to lower the risk of passing HIV to your unborn baby to 1% or less. 90005 90002 Birth Control and HIV 90003 90004 Women with HIV can safely use any form of birth control to prevent pregnancy. But some HIV medicines can interact with hormonal birth control, including the shot, pills, or implants. This can raise the risk for pregnancy. Talk to your health care provider about which form of birth control is right for you.90005 90004 Also, using condoms the right way every time you have sex can help reduce your risk of getting STDs such as gonorrhea and syphilis. 90005.

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