INTRODUCTION

HIV (Human Immunodeficiency Virus) is the virus that causes AIDS. This virus is passed from one person to another through blood, using shared needles and sexual contact. In addition, infected pregnant women can pass HIV to their baby during pregnancy or delivery, as well as through breast-feeding. People with HIV have what is called HIV infection. Most of these people develop AIDS as a result of HIV infection. AIDS (Acquired Immunodeficiency Syndrome) is caused by HIV (Human Immunodeficiency virus) by progressively destroying the body's immune system. HIV breaks down the body's ability to fight infections and certain cancers. People diagnosed with HIV may develop opportunistic infections, which are caused by microbes such as viruses or bacteria that take advantage of the weakened immune system. What would normally be an infection or virus that could fight off by an otherwise healthy person, could become debilitating or even deadly to one with HIV.

Connection between HIV and AIDS

HIV causes AIDS by damaging the immune system cells until the immune system can no longer fight off other infections that it would usually be able to prevent. It takes around ten years on average for someone with HIV to develop AIDS. However, this average is based on the person with HIV having a reasonable diet, and someone who is malnourished may well progress from HIV to AIDS more rapidly.

Structure of the HIV virus

HIV is 90-120 nm icosahedral, enveloped RNA virus, which comprises of an outer envelope consisting of glycoprotein (gp)120 and gp 41.10,14 The nucleocapsid has an outer icosahedral shell and an inner cone shaped core, enclosing the ribonucleoproteins. The genome is diploid, composed of two identical single stranded, positive sense RNA copies and the enzyme reverse transcriptase (RT). 10 The core also contains viral enzymes integrase and protease.

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 Transmission
HIV is transmitted through direct contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV, such as blood, semen, vaginal fluid, preseminal fluid, and breast milk. This transmission can come in the form of anal, vaginal or oral sex, blood transfusion, contaminated intravenous needles, exchange between mother and baby during pregnancy, childbirth, breastfeeding, or other exposure to one of the above bodily fluid.

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CD4 CELL COUNTING

Acquired immunodeficiency syndrome (AIDS) is a progressive deterioration of the immune status of the individual. It is characterized by the progressive depletion of the CD4 T lymphocyte population, which represents a major target of viral infection by the causative human immunodeficiency virus (HIV). Low absolute CD4 counts and the perturbed cytokine network manifest havoc at clinical level. The clinical consequences of HIV infection encompass a spectrum ranging from an acute syndrome associated with primary infection to prolonged asymptomatic state to advanced disease. Consequently, with the staggering worldwide growth of HIV pandemic, the US Public Health Service (PHS) recommended that CD4 T-cell levels be monitored every 36 months in all HIV-infected persons to decrease the clinical complications by initiating prophylaxis for various opportunistic infections due to HIV and for initiating and monitoring the efficacy of antiretroviral therapy. The relationship between CD4 cell count (immunological progression) and viral load (virological progression) is not as neat and simple as the graph below. It is not uncommon for HIV positive patients to find a slight increase or decrease in their CD4 count (sometimes up to 100cells/mm3) and this is not a cause for concern when the CD4 count is above 500cells/mm3. If your viral load was also increasing at this time or if the CD4 count showed a steady decline upon subsequent tests, then this would be considered significant and your doctor may consider ART (antiretroviral therapy) although this depends on other factors. As your CD4 count falls below 500, a fluctuation may be considered significant as ART may be started when your CD4 cell count falls below 350cells/mm3 (in some countries if it is below 200cells/mm3). Changes in your CD4 cell count could be due to other causes but these conditions are uncommon and are usually serious you would have noticed other signs and symptoms at this point. Since you are HIV-positive, there is no reason to attribute this to another condition but you should speak to your doctor to get further clarity on the matter. During the asymptomatic period of HIV infection (marked as clinical latency in the graph), there may not be a significant increase in the viral load and this often occurs in the later stages of the disease.

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CD4+ T-cell levels are an important criterion for categorizing HIV-related clinical conditions according to the CDC classification system and are therefore important in the management of HIV by initiating antiretroviral therapy and prophylaxis for opportunistic infections due to HIV among HIV-infected individuals. However, it has been observed that the CD4 counts are affected by the geographical location, race, ethnic origin, age, gender and changes in total and differential leucocyte counts.

OPPORTUNISTIC INFECTION
The most common OIs are listed here, along with the disease they usually cause, and the CD4 cell count when the disease becomes active:

Candidiasis (Thrush) is a fungal infection of the mouth, throat, or vagina. CD4 cell range: can occur even with fairly high CD4 cells. Cytomegalovirus (CMV) is a viral infection that causes eye disease that can lead to blindness.CD4 cell range: under 50. Herpes simplex viruses can cause oral herpes (cold sores) or genital herpes. These are fairly common infections, but if you have HIV, the outbreaks can be much more frequent and more severe. They can occur at any CD4 cell count. Malaria is common in the developing world. It is more common and more severe in people with HIV infection. Mycobacterium avium complex (MAC or MAI) is a bacterial infection that can cause recurring fevers, general sick feelings, problems with digestion, and serious weight loss. CD4 cell range: under 75. Pneumocystis pneumonia (PCP) is a fungal infection that can cause a fatal pneumonia. CD4 cell range: under 200. Unfortunately this is still a fairly common OI in people who have not been tested or treated for HIV. Toxoplasmosis (Toxo) is a protozoal infection of the brain. T-cell range: under 100. Tuberculosis (TB) is a bacterial infection that attacks the lungs, and can cause meningitis. CD4 cell range: Everyone with HIV who tests positive for exposure to TB should be treated.
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Tuberculosis
Tuberculosis or TB (short for tubercles bacillus) is a common and often deadly infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis in humans. Tuberculosis usually attacks the lungs but can also affect other parts of the body. M tuberculosis is an aerobic gram-positive rod that stains poorly because of its thick cell wall that contains lipids, peptidoglycans, and arabinomannans. Mycobacteria vary in appearance from spherical to short filaments, which may be branched. Although they appear as short to moderately long rods, they can be curved and frequently are seen in clumps. Individual bacilli generally are 0.5-1 m in diameter and 1.5-10 m long. They are nonmotile and do not form spores. One of the distinct characteristics of mycobacteria is their ability to retain dyes within the bacilli that usually are removed from other microorganisms by alcohols and dilute solutions of strong mineral acids such as hydrochloric acid. This ability is attributed to a waxlike layer composed of long-chain fatty acids, the mycolic acids, in their cell wall. As a result, mycobacteria are termed acid-fast bacilli. The mechanisms by which neurovirulence may occur are unknown.

Pulmonary Tuberculosis
Pulmonary tuberculosis is TB that affects the lungs. Its initial symptoms are easily confused with those of other diseases. An infected person may at first feel vaguely unwell or develop a cough blamed on smoking or a cold. A small amount of greenish or yellow sputum may be coughed up when the person gets up in the morning. In time, more sputum is produced that is streaked with blood. Persons with pulmonary TB do not run a high fever, but they often have a low-grade one. They may wake up in the night drenched with cold sweat when the fever breaks. The patient often loses interest in food and may lose weight. There are 2 types of TB:

TB infection: The bacteria are present but are not making you sick or contagious; you are not able to spread the disease. TB infection is also called latent TB or inactive TB. Active TB: The bacteria are present and are causing symptoms; you may be able to spread the disease.

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The symptoms of active TB infection include:

Cough that lasts 3 weeks or longer, and can bring up blood Chest pain Fever Fatigue Unintended weight loss Loss of appetite Chills and night sweats

Bones. TB is particularly likely to attack the spine and the ends of the long bones. Children are especially prone to spinal tuberculosis. If not treated, the spinal segments (vertebrae) may collapse and cause paralysis in one or both legs. Kidneys. Along with the bones, the kidneys are probably the commonest site of extrapulmonary TB. There may, however, be few symptoms even though part of a kidney is destroyed. TB may spread to the bladder. In men, it may spread to the prostate gland and nearby structures Female reproductive organs. The ovaries in women may be infected; TB can spread from them to the peritoneum, which is the membrane lining the abdominal cavity. Abdominal cavity. Tuberculous peritonitis may cause pain ranging from the vague discomfort of stomach cramps to intense pain that may mimic the symptoms of appendicitis. Joints. Tubercular infection of joints causes a form of arthritis that most often affects the hips and knees. The wrist, hand, and elbow joints also may become painful and inflamed. Meninges. The meninges are tissues that cover the brain and the spinal cord. Infection of the meninges by the TB bacillus causes tuberculous meningitis, a condition that is most common in young children but is especially dangerous in the elderly. Patients develop headaches, become drowsy, and eventually comatose. Permanent brain damage is the rule unless prompt treatment is given. Some patients with tuberculous meningitis develop a tumor-like brain mass called a tuberculoma that can cause stroke-like symptoms.

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Skin, intestines, adrenal glands, and blood vessels. All these parts of the body can be infected by M. tuberculosis. Infection of the wall of the body's main artery (the aorta), can cause it to rupture with catastrophic results. Tuberculous pericarditis occurs when the membrane surrounding the heart (the pericardium) is infected and fills up with fluid that interferes with the heart's ability to pump blood. Miliary tuberculosis. Miliary TB is a life-threatening condition that occurs when large numbers of tubercle bacilli spread throughout the body. Huge numbers of tiny tubercular lesions develop that cause marked weakness and weight loss, severe anemia, and gradual wasting of the body.

Tuberculosis: HIV-TB interaction and co-infection

Most common cause of death in people with HIV worldwide. HIV infection increases the likelihood that new infection with M. tuberculosis (due to immune suppression) will progress rapidly to TB disease. HIV is the most potent factor known to increase risk of progression from M. tuberculosis infection to disease. Patients co-infected with HIV and Mycobacterium tuberculosis (M. tb) have a greatly increased risk of developing active TB (annual risk 10% compared with a lifetime risk of only 810% in those solely infected with M. tb) and progress much more rapidly from infection to active disease. This reduces the time available for diagnosis and instigation of treatment.

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REVIEW OF LITRETURE
Scientists have different theories about the origin of HIV, but none have been proven. The earliest known case of HIV was from a blood sample collected in 1959 from a man in Kinshasha, Democratic Republic of Congo. (How he became infected is not known.) Genetic analysis of this blood sample suggests that HIV-1 may have stemmed from a single virus in the late 1940s or early 1950s. The virus existed in the United States since at least the mid to late 1970s. From 1979-1981 rare type of pneumonia, cancer, and other illnesses were being reported by doctors in Los Angeles and New York among a number of gay male patients. These were conditions not usually found in people with healthy immune systems. In June and July of 1981, cases of an extremely uncommon opportunistic infection, Pneumocystis carinii pneumonia, and a very rare skin tumor of endothelial cell origin, Kaposi's sarcoma, were first reported in New York and California in epidemic proportions among previously healthy young homosexual and bisexual men who were not previously known to be predisposed to these diseases. With the rapidly increasing number of cases, it was soon recognized that other life threatening infections and neoplastic diseases were also observed and found to be associated with an unexplained defect in cell mediated immunity, common to each of these patients. By early 1982 the group of disease entities was named the acquired immune deficiency syndrome (AIDS) by the Center for Disease Control (CDC). The term "syndrome" has been used because AIDS does not constitute a single illness, but rather encompasses a wide range of clinical diseases including specific life threatening infections and neoplasm's associated with a profound and irreversible unexplained acquired disorder of cell mediated immunity. Since the appearance of the original definition in September of 1982, the CDC has subsequently revised this definition to accommodate additional syndromes recognized as manifestations of advanced HIV disease. In 1982 public health officials began to use the term "Acquired Immunodeficiency Syndrome," or AIDS, to describe the occurrences of opportunistic infections, Kaposi's sarcoma, and Pneumocystis carinii pneumonia in healthy men. Formal tracking (surveillance) of AIDS cases began that year in the United States. When the first cases of AIDS were reported, many hypotheses were proposed to explain the possible cause(s) of the newly recognized syndrome, but it is now widely accepted that AIDS is caused by a previously unknown human retrovirus, which was initially discovered and isolated in 1983 from patients with persistent generalized lymphadenopathy at the "Institute Pasteur" in Paris. All the related viruses which were discovered were named the human immunodeficiency virus (HIV) by the International Committee on the Taxonomy of Viruses in 1986.

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The cause of AIDS is a virus that scientists isolated in 1983. The virus was at first named HTLVIII/LAV (human T-cell lymphotropic virus-type III/lymphadenopathy-associated virus) by an international scientific committee. This name was later changed to HIV (Human Immunodeficiency Virus). The inescapable conclusion of more than 15 years of scientific research is that people, if exposed to HIV through sexual contact or injecting drug use, may become infected with HIV. If they become infected, most of them will eventually develop AIDS. Each year since 1998, NACO, the National Institute of Health and Family Welfare and the National Institute of Medical Statistics (a body under ICMR) bring out estimates of Indias population living with HIV and AIDS. Released this year in July, the figures for 2006 represent the most accurate reading yet (see box Methodology) of Indias HIV and AIDS numbers. The process of enumeration and the results have been attested to and backed by international agencies UNAIDS and WHO. The 2006 estimates suggest national adult HIV prevalence in India is approximately 0.36 percent, amounting to between 2 and 3.1 million people. If an average figure is taken, this comes to 2.5 million people living with HIV and AIDS; almost 50 percent of the previous estimate of 5.2 million. More men are HIV positive than women. Nationally, the prevalence rate for adult females is 0.29 percent, while for males it is 0.43 percent. This means that for every 100 people living with HIV and AIDS (PLHAs), 61 are men and 39 women. Prevalence is also high in the 15-49 age group (88.7 percent of all infections), indicating that AIDS still threatens the cream of society, those in the prime of their working life. While adult HIV prevalence among the general population is 0.36 percent, high-risk groups, inevitably, show higher numbers. Among Injecting Drug Users (IDUs), it is as high as 8.71 percent, while it is 5.69 percent and 5.38 percent among Men who have Sex with Men (MSM) and Female Sex Workers (FSWs), respectively. HIV counselling and testing services were started in India in 1997. There are now more than 4000 Counselling and Testing Centres, mainly located in government hospitals. Under NACP-III, Voluntary Counselling and Testing Centres (VCTC) and facilities providing Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) services are remodelled as a hub or Integrated Counselling and Testing Centre (ICTC) to provide services to all clients under one roof. An ICTC is a place where a person is counselled and tested for HIV, of his own free will or as advised by a medical provider. The main functions of an ICTC are: Conducting HIV diagnostic tests. Providing basic information on the modes of HIV transmission, and promoting behavioural change to reduce vulnerability. Link people with other HIV prevention, care and treatment services.

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As of today, only 13% of HIV positive people in the country are aware of their HIV status. The challenge before NACO is to make all HIV infected people in the country aware of their status so that they adopt a healthy lifestyle; access life-saving care and treatment and help prevent further transmission of HIV. Thus, counselling and testing services are important components of prevention and control of HIV/AIDS in the country. However, it is not the mandate of an ICTC to counsel and test everyone in the general population. The sub-populations that are more vulnerable or practice high risk behaviour or have higher HIV prevalence levels are the target group for counselling and testing services in the country. In 2006, more than 2.1 million clients accessed counselling and testing services in the ICTC throughout the country. Under NACP-III, the target is to counsel and test 22 million clients annually by the year 2012. HIV counselling and testing services are a key entry point to prevention of HIV infection and to treatment and care of people who are infected with HIV. When availing counselling and testing services, people can access accurate information about HIV prevention and care and undergo HIV test in a supportive and confidential environment. People who are found HIV negative are supported with information and counselling to reduce risks and remain HIV negative. People who are found HIV positive are provided psycho-social support and linked to treatment and care.

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HIV
Rajesh T. Gandhi, MD (August 2, 2010) Treatment Simplification in HIV-Infected Patients In patients who have virologic suppression while receiving abacavir/3TC plus ritonavir-boosted atazanavir, dropping the ritonavir does not compromise regimen potency. Andy Gray, MSc(Pharm), FP (August2, 2010) Increasing Use of Generic Antiretroviral Agents by PEPFAR Programs The proportion of generic medicines procured increased from 15% in 2005 to 89% in 2009, for an estimated total savings exceeding US$320 million. Rajesh T. Gandhi, MD( July 28, 2010) Excess Mortality in Untreated HIV-Infected Patients with High CD4-Cell Counts In a large, multinational cohort study, the death rate among such patients varied by risk group but was higher than in the general population. Abigail Zuger, MD ( July 26, 2010) New Guidelines Stress Early HIV Treatment The International AIDS SocietyUSA is urging clinicians to treat patients when their CD4 counts drop to 500 cells/mm3 or lower and to consider treatment even at higher CD4cell counts. Carlos del Rio, MD, and John A. Marx, MD, FAAEM ( July 26, 2010) Opt-Out HIV Testing in Emergency Departments: Too Little, Too Late In a high-volume urban ED, this strategy modestly increased the number of patients with new HIV diagnoses, but most such patients already had advanced disease.

Carlos del Rio, MD ( July 26, 2010) More on When to Start Antiretroviral Therapy in the Setting of Tuberculosis Treatment In a prospective, randomized trial involving HIV/TB-coinfected patients with CD4 counts >350 cells/mm3, concurrent ART did not improve response to TB therapy. Jamie Robertson (Dec 2, 2008) What are Microbicides? Microbicide research is developing a new method of HIV prevention that will allow individuals to apply a gel, cream, or film prior to sexual activity. George DaleidenMay (21, 2009) Green Tea Chemical May Prevent HIV Infection Promising research worldwide has identified a chemical entity---EGCG--in green tea that prevents sexually-transmitted HIV infection and could inhibit the spread of AIDS. Mohit Joshi on Thu,( 08/21/2008) - 16:55 Kampala - Uganda on Thursday said it had begun a programme to more than double the number of people receiving AIDS drugs to 300,000.

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AIDS
DavidIcke (1/12/2010) - HIV does NOT cause AIDS. HIV does not cause anything. A staggering statement given the hype and acceptance by the scientific establishment and, through them, the public that the HIV virus is the only cause of AIDS. Brent Leung's myth-shattering AIDS documentary, (1/7/2010) Are AIDS / HIV tests a hoax? Documentary footage features conversations with Drs. Niel Constantine and Robin Weiss House of Numbers continues to roil conventional AIDS propagandists who cannot tolerate anyone questioning their "scientific" theories. Shocking truth about AIDS exposed on World AIDS Day with "House of Numbers" un-cut footage (12/1/2009) When Brent Leung started showcasing his groundbreaking new documentary film about AIDS, "House of Numbers". The Mind-Body Connection Part IV: Grandmother was Right; Happiness Aids Digestion (10/16/2009) theres one more piece to add to our healing journey, but before we do that lets briefly summarize the Mind-Body Connection Parts I, II & III. We learned that our thoughts can affect our health; what a neuropeptide is and how it affects. Amid controversy, well known British Homeopath, Jeremy Sherr, complete with wife and children, has recently left the Malvern Hills in the West of England,( 1/28/2009) AIDS and Homeopathy Project Causes a Stir. Kevin Gianni's Renegade Roundtable (9/22/2008) Viruses: The Immune Systems Smallest Enemy That Causes the Biggest Problems. Diet Rich in Plant-foods Aids in Preserves Muscle Mass in Older Adults (8/21/2008) the strength that sometimes leaves many older adults could be maintained and restored by consuming raw vegetables and fruit.

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CD4 -CELL COUNT

People with AIDS may get as their CD4 count decreases. In the past, having AIDS was defined as having HIV infection and getting one of these additional diseases. Today, according to the Centers for Disease Control and Prevention, a person may also be diagnosed as having AIDS if they have a CD4 cell count below 200cells/mm3, even if they don't have an opportunistic infection. AIDS may also be diagnosed if a person develops one of the opportunistic infections and cancers that occur more commonly in people with HIV infection. These infections are unusual in people with a healthy immune system. Braz J Infect Dis vol.12 no.6 Salvador (Dec. 2008) CD4+ cell counts in patients with different clinical manifestations of tuberculosis Tuberculosis is the prototype of infections that require a cellular immune response for their control. It has been shown that CD4+ T-lymphocytes are most important in the protective response against Mycobacterium tuberculosis. Bethina Abrahams (Jun 15, 2007) Relationship between CD4 count and CD4% in HIVinfected people OBJECTIVE: To describe the relationship between absolute CD4 count and CD4%, and the influence on this of gender, risk group, age, a diagnosis of AIDS, use of zidovudine (ZDV) therapy and PCP prophylaxis. Singh R, Arora D ,et al; (10/3/2009) Clinical Profile Of HIV Infected Patients and Absolute Cd4 and Cd8 Counts. The present study was planned to study the clinical profile of HIV positive patients presenting to a tertiary care hospital, absolute CD4 and CD8 cell count in HIV positive patients at the time of presentation and the association of CD4 and CD8 cell counts with the predominant clinical infection at the time of presentation. J Gen Intern Med. (1998 February); Diagnosing HIV Related diseases Using the CD4 Count as a Guide Alan C Jung, MD and Douglas S Paauw, MD Received from the Department of Medicine, University of Washington, To summarize current information on the relation between CD4 counts and the risk of different HIV-related diseases. LM Yu, PJ Easterbrook and T Marshall HIV Epidemiology Unit, Chelsea and Westminster Hospital, London, UK. To describe the relationship between absolute CD4 count and CD4%, and the influence on this of gender, risk group, age, a diagnosis of AIDS, use of zidovudine (ZDV) therapy and PCP prophylaxis. Nancy Crum-Cianflone, M.D., M.P.H. (November 19, 2009)Overweight People With HIV See Lower CD4 Gain While on HIV Medications, Study Suggests. Journal Watch (June 1, 2009) A Hint at Why Some People on HAART Experience a Falling CD4 Count.
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aidsmap.com (March 28, 2008) Study Confirms Importance of CD4 Increase, Undetectable Viral Load after Starting HAART. In Kaiser Daily HIV/AIDS Report, from Henry J. Kaiser Family Foundation (September 28, 2006) HIV Viral Load Is Not Reliable Indicator for CD4+ T cell Counts. aidsmap.com (August 29, 2005) To Start or Not to Start? CD4 Percentage May Provide Guidance Among people with a CD4 count above 350, HIV disease progression is found to be 3.6 times more likely for those with a CD4 percentage below17%. In Positively Aware, from (May/June 2002) Test Positive Aware Network the Buzz: The Disconnect SyndromeA controversial Dilemma. Yi Zhang, Zhaojun Sun, Hugues Nicolay, Ralf G. Meyer, Nicolina Renkvist, Vincent Stroobant, Jurgen Corthals, Javier Carrasco, Alexander M. M. Eggermont, Marie Marchand, Kris Thielemans, Thomas Wlfel, Thierry Boon and Pierre van der Bruggen The Journal of Immunology, 2005Monitoring of Anti-Vaccine CD4 T Cell Frequencies in Melanoma Patients Vaccinated with a MAGE-3 Protein. Tsertsvadze T, Sharvadze L, Butsashvili M; International Conference on AIDS. Int Conf AIDS. 1996 Jul 7-12; 11: 302 (abstract no. Th.B.4297). Monitoring of CD4+CD6+, HLADR+ and CD8+CD38+ lymphocyte counts in HIV-infected patients in prospective followup study. THOMAS PUTZ, REINHOLD RAMONER, HUBERT GANDER, ANDREA RAHM, GEORG BARTSCH, LORENZ HLTL and MARTIN THURNHER Volume 24, (Number 6,2006) Journal of Clinical Immunology Monitoring of CD4+ and CD8+ T-Cell Responses After Dendritic Cell-Based Immunotherapy Using CFSE Dye Dilution Analysis. Keith Alcorn (22 May 2008) Regular CD4 monitoring, big rise in HIV diagnosis, key to reducing AIDS death rate. Polly Clayden, HIV i-Base (June 2008. Monitoring patients on antiretroviral therapy in resource-limited settings with viral load, CD4 count, or clinical observation alone. JAIDS Journal of Acquired Immune Deficiency Syndromes (1 February 2008) Novel LowCost Assay for the Monitoring of CD4 Counts in HIV-Infected Individuals. PLoS Med. (2005 July 19) A Microchip CD4 Counting Method for HIV Monitoring in Resource-Poor Settings William R Rodriguez, 1,2,3 Nicolaos Christodoulides,4 Pierre N Floriano,4 Susan Graham,3 Sanghamitra Mohanty,4 Meredith Dixon,1 Mina Hsiang,1 Trevor Peter,5 Shabnam Zavahir,5 Ibou Thior,5 Dwight Romanovicz,4 Bruce.
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DART Trial Team. The Lancet, Early Online Publication, 9 December 2009 Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomized non-inferiority trial.

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Pulmonary Tuberculosis
The convergence of HIV and tuberculosis (TB) pandemics in developing countries has been a disaster practically unequalled in medical history. Sub-Saharan Africa bears the brunt of the 8 million annual new cases of active TB worldwide. Thirteen of the 15 countries with the highest incidence rates of TB per capita lie within this region. Moreover, TB is the leading cause of death among HIV-infected persons. Alarmingly, fewer than half of TB cases in HIVinfected patients are diagnosed before death. The factors underlying our failure to rapidly diagnose and effectively treat TB are multiple. Patients co-infected with HIV and Mycobacterium tuberculosis (M. tb) have a greatly increased risk of developing active TB (annual risk 10% compared with a lifetime risk of only 810% in those solely infected with M. tb) and progress much more rapidly from infection to active disease. This reduces the time available for diagnosis and instigation of treatment. Issues surrounding stigmatization of persons living with HIV lead to reluctance to seek medical assistance, and limited health-care provision in many resource-poor countries undoubtedly compounds the access to treatment. Despite great advances in immunology, microbiology, and drug development, TB remains among the great public health challenges. Poverty; lack of functioning public health infrastructure; lack of funding to support basic research aimed at developing new drugs, diagnostics, and vaccines; and the co-epidemic of HIV continue to fuel the ongoing epidemic of TB. The World Health Organization (WHO) estimates that one third of the world's population is infected by Mycobacterium tuberculosis. An estimated 8.8 million new tuberculosis cases were recorded in 2005 worldwide, 7.4 million in Asia and sub-Saharan Africa. A total of 1.6 million people died from tuberculosis, including 19500 patients infected with HIV. In 2005, the tuberculosis incidence rate was stable or in decline in all 6 WHO regions. However, the total number of new tuberculosis cases was still rising slowly; the case-load continues to grow in the African, eastern Mediterranean, and Southeast Asia regions. Johnson J L, Vjecha M J, Okwera A, Hatanga E, Byekwaso F, Wolski K, et al. Impact of human immunodeficiency virus type-1 infection on the initial bacteriologic and radiographic manifestations of pulmonary tuberculosis in Uganda. Int J Tuberc Lung Dis 1998;2:397-404. Tarakad S Ramachandran, MBBS, FRCP(C), FACP,( Dec 4, 2008 ) Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Tuberculoma is the round gray mass in the left corpus callosum. The red meninges on the right are consistent with irritation and probable meningeal reaction to tuberculosis.
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 David C. Dugdale, III, MD, Professor of Medicine, (5/25/2010) University of Washington School of Medicine; When Tuberculosis Travels Beyond the Lungs. TB alone is difficult enough to treat. Unfortunately, it can also spread beyond the lungs to other parts of the body.

Diana Rodriguez Medically reviewed by Pat F. Bass III, MD, MPH (4/23/2010) Dealing with tuberculosis involves a long treatment regimen, potential medication side effects, and possible complications, which is difficult enough for a patient. Whats more, tuberculosis can spread beyond the lungs, causing other infections. While pulmonary tuberculosis most commonly attacks the lungs, the bacteria do not necessarily stay put.

Tarakad S Ramachandran,( Dec 4, 2008) MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital. J. W. V. Wait1, L. Stanton1 and J. F. Schoeman2 (Year : 2004 | Volume : 52 ) Department of Psychology, University of Stellenbosch, Republic of South Africa 2 Department of Paediatrics and Child Health, Tygerberg Hospital and University of Stellenbosch, Republic of South AfricaTuberculosis Meningitis and Attention Deficit Hyperactivity Disorder in Children. Crampin A C, Floyd S, Mwaungulu F, Black G, Ndhlovu R, Mwaiyeghele E, et al. Comparison of two versus three smears in identifying culture-positive tuberculosis patients in a rural African setting with high HIV prevalence. Int J Tuberc Lung Dis 2001. Blair E B, Brown G L, Tull A H. Computer files and analyses of laboratory data from tuberculosis patients. II. Analyses of six years' data on sputum specimens. Am Rev Respir Dis 1976. Angeby K A K, Hoffner S E, Diwan V K. Should the 'bleach microscopy method' be recommended for improved case detection of tuberculosis? Literature review and key person analysis. Int J Tuberc Lung Dis 2004.

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AIMS AND OBJECTIVES

1. To establish the diagnosis HIV infection by serological methods. 2. To monitor CD4 leucocyte count by flowcytometery of these HIV positive patient undergoing ART. 3. To diagnose Pulmonary Tuberculosis and other opportunistic infections in these HIV positive patient. 4. Correlation of CD4 count and opportunistic infection.

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MATERIAL AND METHOD

In this study we included total no. of 120 patients who were diagnose to have HIV infection based on a positive anti HIV-1 and HIV-2 antibody test. These patients were visiting HIV-ART center of SMS medical college and hospital. CD4 leucocyte count was performed for all these 120 patients as a guide to start the ART. Standard, precautions and method was used for the collection of blood specimen and separation of sera. Various test for HIV antibody detection, CD4 count and diagnosis of associated opportunistic infections were used, methodology of which is mention as below:-

Step 1
Blood collection
Blood should never be collected from vein proximal to an induction site. If collecting directly from an indwelling line, the first few mL of blood should be discarded and a note of the collection site made on the request form. If a heparinized syringe is used (e.g. for arterial blood gases) the sample must not be submitted for coagulation studies.

Technique
Venous stasis (tourniquet application) should always be minimized. Cell counts, and the levels of proteins (including enzymes) and protein bound substances (e.g. calcium, cholesterol, and many drugs) will be increased by prolonged or excessive venous stasis. Venipuncture should be clean and atraumatic. If difficulty is experienced, the attempt should be abandoned. A second venipuncture (preferably by a more experienced collector) should be attempted with a new needle and syringe, or evacuated container, at a different site.

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Tubes
Blood must be added to the tubes immediately but gently and without frothing. If a syringe with needle is used, the needle must be removed (see Safety below) before adding blood to the specimen tubes. If tubes containing anticoagulant are used, the correct amount of blood must be added to the tube (usually indicated by a mark on the label) and mixed immediately by through but gentle inversion. Tubes should never be shaken and blood should never be poured from one container to another. Blood culture specimens should, if possible, be collected from a separate venipuncture site. If a single venipuncture is necessary, the blood culture bottles must be inoculated first. The needle should then be removed for addition of blood to the remaining specimen tubes. Specimen tubes should be labeled immediately after the specimen is collected.

Safety
All blood samples must be treated as potential infection risks. Care should be taken to avoid over-filling of tubes which is likely to be associated with leakage of blood and contamination of the external surface of the container. Needles must be disposed of with care into a sharps container. Syringes, swabs or any other blood contaminated materials must be placed in an appropriate contaminated waste container immediately after use. Evacuated collection systems are now frequently used for blood collection as there is less chance of blood spillage and thus exposure to blood-borne diseases.

Specimen transport
Blood samples should be transported to the laboratory in biohazard bags with minimum delay. If delay is inevitable it is generally better to refrigerate samples in the interim. However refrigeration may itself cause art factual changes in the results.

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Electrolytes
Blood for electrolytes should not be refrigerated; if delay is anticipated, plasma should be separated and stored at 4degree C. Blood cultures and CSF specimens for culture must not be refrigerated. Unseparated samples of blood must never be frozen. Samples should not be subject to temperatures of >25degree C, even for short periods. Some tests involve especially labile components (e.g. Complement) and blood must be transported to the laboratory immediately.

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 Step 2
HIV Testing
HIV tests are used to detect the presence of the human immunodeficiency virus in serum, saliva or urine. Such tests may detect HIV antibodies, antigens or RNA Contents. The window period is the time from infection until a test can detect any change. The average window period with antibody tests in 22 days. Antigen testing cuts the window period to approximately 16 days and NAT (Nucleic Acid Testing) further reduces this period to 12 days. Performance of medical tests is often described in terms of :Sensitivity: The percentage of the results that will be positive when HIV is present. Specificity: The percentage of the results that will be negative when HIV is not present,

All diagnostic tests have limitations and sometimes their use may produce erroneous or questionable results. False positive results are when the test concludes HIV is present when, in fact, the person is not infected. False negative results are when the test concludes HIV is not present, when in fact the person is infected. Nonspecific reactions hypergammaglobulinemia or the presence of antibodies directed to other infectious agents that may be antigenically similar to HIV can produce false positive results. Autoimmune diseases, such as systemic lupus erythematous, can also cause false positive results.

MICROLISA HIV Ag & Ab

Microlisa HIV (Ag & Ab) is an in- vitro qualitative enzyme immunoassay for the detection of antibodies to HIV-1 and/or HIV-2 and HIV-1 P24 antigen in human serum or plasma. It is intended for screening of blood donors or other individuals at risk for HIV-1 and/or HIV-2 infection and for clinical diagnostic testing.

SALIENT FEATURES
Significant reduction in window period. Enhanced Specificity & Sensitivity. Easy to use on Automated and Semi automated Processor. Color Ceded reagents to monitor procedural steps. Result in 90 minutes. Self-Life: 12 Months.

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Principle of the testing

Microlisa HIV (Ag & Ab) test is an enzyme immunoassay based on Sandwich ELISA. Recombinant proteins gp41, C terminus of gp 120, and gp 36 for HIV-1 AND HIV-2 representing immunodominant epitopes and P24 antibodies are coated onto microtiter wells. Specimens and controls are added to the microtiter wells followed by addition of enzyme conjugate (HIV & 2 antigen and HIV-1 P24 antibodies linked with HRPO). A sandwich complex is formed in the well where in HIV-1 or HIV-2 antibodies or P24 antigen (from serum sample) is sandwiched between the antigens & antigen HRPO and antibody & antibody HRPO conjugate. The plate is then washed to remove unbound material. Finally substrates solution containing chromogen and hydrogen per oxide is added to the wells and incubated. A blue color will develop in proportion to the amount of HIV-1 and/or HIV-2 antibodies and/or HIV-1 antigen present in the specimen. The color reaction is stopped by a stop solution. The enzyme substrate reaction is read by EIA reader for absorbance at a wavelength of 450nm. If the sample does not contain HIV-1 or HIV-2 antibodies or HIV-1 P24 antigen, then enzyme conjugate will not bind and the solution in the wells will be either colorless or only faint background colors develops.

Assay procedure of Microlisa: Add 100ml sample diluent to A-1 well a blank. Add 100ml negative control in each well no. B-1 and C-1 respectively. Add 100ml positive control in D-1, E-1 and F-1 wells. Add 100ml sample diluent in each well starting from G-1. Add 100ml sample in each well starting from B-1 (without A-1). Incubate at 37 degree C+- 2degree C for 30 min with cover seal. After the incubation time is over, take out the plate from the incubator and wash the wells 5 times with the working wash solution. Add 10ml of working conjugate solution in each well including A-1. Incubate plate at room temperature [20-30degree C] for 30 min in dark. Add 50ml of stop solution. Read absorbance at 450nm within 30 minutes in ELISA READER after blanking A-1 well.

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Procedure:
Add 150micro liter of sample diluents to each mirocuvette using micropipette. Add 150 micro liter of sample to each of the above microcuvettes containing sample diluents using micropipette. Mix sample. Cut open the foil pouch & take out the rapid no. of combs. mark the sample no. on the space provided on the comb & place it on to the rows of corresponding microcuvittes for 15 sec. In the meantime fill another requirement set of microcuvittes which have not been previously used, with protein A conjugate directly from the vial by touching the nozzle tip to the side of the well of the cuvettes and squeezing it or dispense 300 microliter surface of the comb. Hold the comb vertically with the tip pointing down and immerse into the washing solution. Wash 10 times carefully by moving the comb forward and backward in the washing solution. Blot the tips of the arm again on the absorbent material. Place the comb into microcuvittes containing protein A conjugate and incubate for 10 min. at room temperature. During incubation withdraw & insert the comb in the microcuvittes for 15 sec. Wash the comb again described previously Place the comb o clean surface, reactive side up & allow it to air dry. Read result only after the comb is completely dry. Discard the used microcuvittes after ruining the test. Discard the comb after reading the results considering it to be potentially infectious.

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1. SD BIOLINE HIV-1/2 3.0 TEST The SD BIOLINE HIV-1/2 3.0 test is an immunochromatographic (rapid) test for the qualitative detection of antibodies of all isotypes (IgG, IgM, IgA) specific to HIV-1 and HIV-2 simultaneously in human serum, plasma or whole blood.

Materials Provided:SD BIOLINE HIV test kit contains the following items to perform the assay. Test Device Individually foil pouched with Desiccant Capillary pipette 10 Microliter Assay Diluent Lancets Negative Control (Optional ) Positive Control (Optional ) Package insert

Procedure: Add 10 micro liter serum/ plasma into the sample well. Add 4 drops of assay dilutions into the sample well. Interpret test result in 5-20 minutes. Pink color appears on test line indicate positive result.

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2. COMBAIDS TEST The test, a comb-shaped, plastic dipstick that is now being manufactured in developing countries, detects antibodies produced by the body's immune system in response to infection by the HIV viruses.

Materials Provided:COMBAIDS RS Advantage-ST test kit contains the following items to perform the assay. Washing buffer (5x) Colloidal gold signal reagent Sample diluent Negative control Positive control Antigen & control reagent coated combs

Procedure: Add 2 drops (0.1 ml) of sample diluent to the microtest well. Add 2drops (0.1 ml) of sample mix sample with diluent by repeated aspirating with disposable plastic dropper tip. Place the comb into the diluted sample and incubate exactly for 10 minutes at room temperature. In the meantime, dispense 4 drops (0.2 ml) of colloidal gold signal reagent into another set of unused microtest wells. Hold the comb vertically with tips pointing down and rock them forward and backward in the wash solution for a total of ten times. Place the comb into well containing colloidal gold signal reagent and incubate exactly for 10 minutes at room temperature. Place the comb on a clean surface; allow the comb to air dry completely before reading the results. Pink dot appears on test line indicate positive result.

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3. SIGNAL TRIDOT TEST HIV antigens are immobilized on a porous immunofilteration membrane. Sample and reagents pass through the membrane and are absorbed into the underlying absorbent. As the patient's sample passes through the membrane, HIV antibodies, if present, bind to the immobilized antigens. Conjugate binds to the Fc portion of antibodies to give distinct pinkish purple DOT against a white background.

Materials Provided: Test device Wash buffer Signal reagent Disposable plastic droppers

Procedure: Add 2 drops (100 microliter) of wash buffer to the device. Add 1 drop (50 microliter) of patients sample using the disposable plastic dropper. Add 2 drops (100 microliter) of wash buffer. Add 2 drops (100 microliter) of signal reagent. Add 3 drops (150 microliter) of wash buffer. Read the result after 2 minutes, presence of two pinkish red dots indicates positive result.

Reactive

Negative

Read results immediately

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 MONITERING OF CD4 LEUCOCYTE OF HIV POSITIVE PATIENT

BD FACS Calibur instrument overview: The BD FACS calibur is a five-detector flow cytometer that consists of fluidic, optical and electronic systems, with built-in air cooled, argonion laser. The BD FACS calibur system consists of :1. Sensor unit: It houses the power switch, the fluid control panel, the fluids drawer and the sample injection port (SIP). 2. The BD FACStation data management system and printer. 3. Application software packages - BD FACS comp - BD MultiSET - BD Cell Quest Pro.

CD4 ENUMERATION USING BD FACS CALIBUR MACHINE

Materials required for CD4 enumeration:

BD TriTEST CD3/CD4/CD45 reagent is provided in 1mL of buffered saline with bovine serum albumin and 0.1% sodium azide. TruCOUNT Tubes: TruCOUNT Tubes contain a freeze-dried pellet of fluorescent beads in a single use tube. Each TruCOUNT pouch contains 25 tubes, sufficient for 25 tests. CaliBRITE 3 beads. FACS Lysing Solution (10X), 100 mL. Reagent-grade (distilled or deionized) [DI] water. K3 EDTA VACUTAINER blood collection tubes or equivalent. Disposable 12 x 75-mm Falcon capped polystyrene test tubes or equivalent (if not using TruCOUNT Tubes). Vortex mixer. Micropipettor with tips (BD Electronic Pipette. Bulk dispenser or pipettor (450 L) for dispensing FACS Lysing Solution. Sheath fluid TruCOUNT Controls. Lysable whole blood control (available commercially).
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 Storage of reagents:
The reagent is stored at 2-8C. It should not be used after the expiration date shown on the label. The TRU count tubes should be stored in their original foil pouch at 2-25 C.

Procedure for staining the cells:

For each patient sample, a TruCOUNT Tube was labeled with the sample identification number. 20 L of TriTEST CD3/CD4/CD45 reagent was pipetted into the bottom of the tube. While using the TruCOUNT Tube, pipetting was done just above the stainless steel retainer without touching the pellet. 50 L of well-mixed, anticoagulated whole blood was pipetted into the bottom of the tube by reverse pipetting technique onto the side of the tube just above the retainer.

Reverse Pipetting for sample preparation

When TruCOUNT Tubes are used, the addition of a precise volume of blood is critical to achieving the result. Reverse pipetting technique takes advantage of two stops in a pipette. For normal pipetting, the button is depressed to the first stop. Sample is drawn up by releasing the button and then expelled by pressing to the first stop again. For reverse pipetting, the button is depressed to the second stop. When the button is released, excess sample is drawn up into the tip. A precise volume of sample is expelled by pressing the button to the first stop, leaving excess sample in the tip. The tube was capped and vortexed gently to mix. This was incubated for 15 minutes in the dark a room temperature (20-25C). 450 L FACS Lysing Solution was added to the tube. The tube was capped and vortexed gently to mix and incubated for 15 minutes in the dark at room temperature (20-25C). The sample was then ready to be analyzed on the flow cytometer.

FLOW CYTOMETERY
FLOW CYTOMETER PROCESSING: Firstly, check the machine fluids: Sheath fluid Waste Check that UPS, transforms, extension board, & FACS caliber machine & printer on. Check for bubbles. Prime (with distilled water 3ml for 3 to 4 times).
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On the Computer and then click work list manager on desktop. After accept it click on FACS COMPUTER.

PREPAIRING BD CALIBRATE BEADS: Quality control run take two tubes A & B. 1ml sheath fluid in tube A. 3ml sheath fluid in tube B. Take unlabeled beads and put 1 drop in both tubes A & B. Add 1 drop each of PE-PERCP & FITC drop in 3ml tube. Vortex both tubes properly. Set the tubes in rack and cover it properly. After this, come back and computer screen on the page displayed. Then click RUN and follow messages on the top of screen. Press RUN and high button on cytometer. Event rate appears (quality control RUN). Print out comes then press (quit). Automatic cleaning starts after finish the cleaning press continue. Work list manager page appears and fill up the data of patients. Put samples on the rack from 1 to 38 no. not on 39 & 40. Press assign rack then press RUN tests and after that click SAVE. Press medium button on cytometer. Samples run automatically after proper mixing. Print on comes simultaneously.

BD FACS Calibur shut down:Cleaning with 10% bleach The fluid control was set to RUN. A tube containing 3 ml of 1:10 bleach solution was installed on the SIP with the support arm to the side and left for one minute. The bleach solution was allowed to run for 5 minutes on HI, after moving the support arm under the tube. A tube containing 3 ml of DI water was installed on the SIP with the support arm to the side and let run for 1 minute. Water was allowed to run for 5 minutes on HI after moving the support arm under the tube. The DI water tube was removed and discarded. The fluid control was set to STNDBY. A tube containing 1 ml of DI water was placed on the SIP. The computer was turned off. The BD FACS caliber was turned off.

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QUALITY CONTROL
Run a control sample daily from a normal adult subject or a commercially available whole blood control to optimize instrument settings and as a quality control check of the system. The BD Tritest isotype control reagent is optional to set fluorescence markers for detecting the presence of nonspecific staining. Use commercial controls providing established values for percent positive and absolute counts with each run to assess system performance. Visually inspect the CD45 vs SSC dot plot. The lymphocyte population should appear as a bright, compact cluster with low SSC. Monocytes and granulocytes should also appear as distinct clusters. Do not proceed with analysis if populations are diffuse and there is little or no separation between clusters. Figure 1 and Figure 2 and Figure 3 are representative data from hematologically normal adult samplestained with BD Tritest CD3/CD4/CD45 in a BD Trucount tube.

Figure 1: Ungated CD45 vs SSC dot plot CD45+ lymphocytes

Figure 2: Ungated CD3 vs CD4 dot plot

Figure 3: Lymphocyte-gated CD3 vs CD4 dot plot

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Result Results are reported as the percentage of positive cells per lymphocyte population or as the number of positive cells per microliter of blood (absolute count). Calculating Absolute Counts During analysis, the absolute number (cells/L) of positive cells in the sample can be determined by comparing cellular events to bead events. If BD Multiset software is used, absolute counts will be determined automatically. For manual data analysis using BD CellQuest or other software, simply divide the number of positive cellular events by the number of bead events, and then multiply by the BD Trucount beadconcentration. Limitations Laboratories must establish their own normal reference ranges for the BD Tri test CD3/CD4/CD45 reagent parameters that can be affected by gender of patient, age of patient, and preparative technique. Race of patient and individual variations of epitope expression can also have an effect, although sufficient data is not available to establish this. Age, gender, clinical characteristics, and race of patients should be known when a reference range is determined. BD Tritest CD3/CD4/CD45 reagent has not been validated for use with heparin or acid citrate dextrose (ACD) liquid anticoagulants in determining absolute counts with BD Trucount tubes. BD Tritest CD3/CD4/CD45 reagent is not intended for screening samples for the presence of leukemic cells or for use in phenotyping samples from leukemia patients

MICROBIOLOGICAL EXAMINATION: Specimens for microbiological examination must be appropriated e.g. sputum rather than saliva. In general, specimens should be collected into, and transported in, a sterile container. Aspirated pus may be transported in a syringe, which must be capped immediately the needle has been removed and disposed of safely. Specimens should be delivered promptly to the laboratory. Although many specimens will tolerate a delay of several hours if refrigerated, cerebrospinal fluid must be transported to the laboratory immediately, without refrigeration. Similarly, for the detection of Neisseria gonorrhoeae and other fragile organisms, special arrangements may be needed: e.g. express delivery, inoculation o plates at the time and place of collection, provision of special transport containers.

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 Pulmonary Tuberculosis Testing

Direct smear examination
For the direct examination of sputum: conventional staining with Carbol-fuchsin [ZiehlNeelsen (ZN)] or Kinyoun stain using light microscopy.

Staining methods
A. ZiehlNeelsen (ZN) Stain:Materials Provided: Carbol fuchsin :Basic fuchsin = 5gm Phenol = 25gm 95%ethanol = 50ml Distilled water = 500ml Dissolve the basic fuchsin in phenol; by placing over a boiling water bath for 5 min. shaking the contents from time to time. Add alcohol after the solution has been made. Mix thoroughly. Add distilled water. Filler before use. Acid alcohol:Hydrochloric acid = 3ml (concentrated) 95%ethanol = 97ml Counterstain:Methylene blue = 0.3gm Distilled water = 100ml

Procedure: Prepare the smear by spreading the material over an area 1*2cm. air dry and heat fix the smear. Floor the slide with Carbol fuchsin. Heat the slide to steaming with a Bunsen burner and let stand for 5 min. if the smear dries, add more stain. Wash the slide with water. Flood the smear with methylene blue and Counterstain for 1to 2 min. Wash with water and air dry. DOES NOT BLOT DRY. Examine under oil immersion objective lens of the microscope.
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B. Kinyoun stain:Materials Provided: Carbol fuchsin :Basic fuchsin = 4gm Phenol = 8gm 95%ethanol = 20ml Distilled water = 100ml Dissolve the basic fuchsin in phenol; by placing over a boiling water bath for 5 min. shaking the contents from time to time. Add alcohol after the solution has been made. Mix thoroughly. Add distilled water. Filler before use. Acid alcohol:Hydrochloric acid = 3ml (concentrated) 95%ethanol = 97ml Counterstain:Methylene blue = 0.3gm Distilled water = 100ml

Procedure: Prepare the smear by spreading the material over an area 1*2cm. air dry and heat fix the smear. Floor the slide with Kinyoun Carbol fuchsin for 5 min. NO heating required. Wash the slide with water and decolourize with alcohol for 2 min. Rinse with water and drain. Flood the smear with methylene blue and Counterstain for 1to 2 min. Wash with water and air dry. Examine under oil immersion objective lens of the microscope (1000x).

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CHART-1:-

Sex distribution

38, 32%

male fema 82, 68%

No. of male and female patient in total number of HIV +ve patient

CHART-2:50 45 40 35 30 25 20 15 10 5 0 6 MONTH -12 YEARS 13-25

AGE GROUP
M F T

NO. OF PATIENTS

26-35

AGE

36-45

46-55

56-65

No. of male and female patient in various age groups TABLE: S. No. 1. 2. 3. 4. 5. 6. AGE GROUP 6 months- 12 year 13-25 26-35 36-45 46-55 56-65 GRAND TOTAL MALES 9 6 23 32 8 4 82 FEMALES 3 4 18 13 0 0 38 TOTAL 12 10 41 45 8 4 120

HIV +ve males and females patient of various age groups

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CHART-3:-

CD4 Count at start of ART

8, 7% 13, 11% Below 50 31, 26% 51-100 27, 22% 101-200 201-350 Above 350 41, 34%

Range of CD4 count in HIV+ve patients

CHART-4:-

DISTRIBUTION OF OPPORTUNISTIC INFECTION

23, 15% 34, 22% TUBERCULOSIS TBM FUNGAL INFECTION 16, 10% 20, 13% 28, 18% 31, 20% DIARRHOEA ARI OTHER WITHOUT OI

3, 2%

Distribution of opportunistic infection of HIV +ve patients

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CHART-5:35 30 25 20 16 15 10 5 1 0 below 50 51-100 101-200 201-350 above 350 9 4 1 2 14 16 25 22 20 16 25 No. of patient of ART No. of patient months No. of patient 12 months 33

CD4 range

Range of CD4 counts in HIV+ve patients under 12 months duration of ART.

TABLE: CD4 RANGE No. of patient at start of ART 9 16 25 16 2 No. of patient after 6 months 1 4 22 25 16 No. of patient after 12 months 0 1 14 20 33

Below 50 51- 100 101- 200 200- 350 Above 350

Range of CD4 counts in HIV+ve patients under 12 months duration of ART.

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CHART-6:16 14 12 11 10 8 8 15

14

No. of Patients

10 8 6 4 2 0 Below 100 Below 200 200-400 2

No. of Patient befor start of ART No. of Patient after of ART Above 400

Range of CD4 counts in patients are suffering from HIV and TB both TABLE: -

CD4 RANGE

No. of patient before start of ART

No. of patient after start of ART

Below 100 Below 200

15 8

2 8

200-400 Above 400

11 -

14 10

Range of CD4 counts in patients are suffering from HIV and TB both

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Discussion:In study of 120 HIV positive patients, 82 patients are male and 38 patients are female. The percentage of male and female patients is 68% and 32% respectively. In this study of 120 patients the data obtained show that the 32% were females are having HIV infection approximately half in number of males affected. The incidence of HIV in males could be due to their high-risk sexual behavior, the more mobility and travelling habits and the infection being passed to their females. HIV positive patients of different age group of 0-12, 13-25, 26-35,3645,46-55,55-65 show the number of HIV positive patients are 12,10,41,45 and 8 respectively. The occurrences of HIV infection in childrens are 10% and the highest frequency of infection is found in age group 36-45 in which the maximum number of HIV positive patients exist. In every age group, cases of male HIV positive are greater than female cases. The graph chart 1, chart 2 and table 2 is the evident that the age group 26-45 is having maximum number of HIV infected males and females. Both might be because of the age of higher sexual activity, otherwise in younger age group and older people HIV less infects. The above 10% patients in the age group of 6 months-12 year indicate the mother to child transmission of HIV and non-sexual method of transmission of the disease. CD4 leucocytes count normally is found 350cells/mm3 and above, CD4 is being used as an indicator to start ART in HIV infected patients. Normally CD4 count lower than 200cells/mm3 has been used as the criteria for starting ART but in some cases around 350cells/mm3 is also used for start the ART. Regular monitoring of CD4 count is done at the interval of every 6 months to monitor the progress of the disease. The analysis of CD count at start of ART in range of 0-50, 51-100, 101-200, 201-350and above 350 cells/mm consist 11%, 26%, 34%, 26% and 7% cases. To determine the role of ART in CD count, we study 68 cases under duration of 12 months in various CD count range. The study done in CD count range 050, 51-100,101-200,201-350 and above 350 consist 9, 16, 25, 16, 2 cases respectively at start of ART. Table 2 shows that after 6 months the CD count increase of these patients and only 5 patients exist at CD count below 100 which is 25 at start of ART .After 12 months of ART CD count increases significantly and only 1 patient exist at CD count below 100. But exceptions exist always everywhere, in 3 cases the CD count decrease inspite of increase due to some reasons which is unknown in these cases. From chart 5 and table 2 it is shown that the CD4 counts at the start of the ART and after 6 and 12 months of ART counts are improving in almost all the patient. CD4 counts improved in most of the cases in ART within 6 months of ART while poor response or further deterioration of CD4 count in patients on ART might be due to poor individuals response to ART and improvement in CD4 count. Regarding OI which are common in HIV infected patients are TB, TBM, Diarrhea, Fungal infection (mostly Aspergillus, Penicillium, Candida etc.), ARI, Herpes, Genital herpes etc. The analysis of different OI in 120 HIVpositive patient shows that the number of patients infected with TB, Fungal infection, Diarrhea, TBM, other OI is 34,31,28,20 and 3 respectively. These analyses explain that TB is more common OI found in HIV infected patients, than fungal is the 2nd common OI and Diarrhea is the 3rd common OI. In 120 cases, only 23 cases are found without any
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OI. So, on the basis of our study the possibility of OI in HIV positive patients are 80.83% that is a greater number and indicate that mostly patients are suffering from one or other OI. HIV and TB co-infection is a well-established fact in which HIV infection predisposes to TB infection and vice versa. The correlation between CD4 count and different OIs could not be established because the exact time of occurrence of the different OI was unknown. Cases in this study are showing a good CD4 count and having any OIs, no OIs are seen in many cases of poor CD4 count.

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SUMMARY AND CONCLUSI ON:The present study conducted to learn about the Monitoring of CD4 leucocyte count in HIV positive patients undergoing ART and associated pulmonary tuberculosis it was carried out in the HIV section of the department of Microbiology & Immunology, S.M.S. Medical College, Jaipur. The diagnosis of HIV infection is carried out by detecting the HIV-1 and HIV-2 antibodies. Now we collect the sputum of 120 HIV patients for the direct examination of sputum: Conventional staining with Carbol-fuchsin [ZiehlNeelsen (ZN)] or Kinyoun stain using light microscopy direct smear examination of Pulmonary Tuberculosis. From the study, following conclusion has been drawn it: Male are more HIV positive than compare with female. These studies indicate that HIV disease is widely spread in male than female. The study of 120 HIV positive patients of different age group, we find that, older men are markedly more likely than younger men to have been circumcised, out of 120, 84 cases are under 26-45 age group and In every age group, cases of male HIV + ve are greater than female cases. Low CD4 count is also the indicator to start the ART and also monitoring of CD4 count acts as a prognostic factor. After ART treatment CD4 range of HIV positive patients is continuously increased. This study shows that ART play an important role in developing immunity against different microorganisms by increase in CD count. On the Basis of observations of all opportunistic infection who infect HIV positive patients. Commonest OI is Pulmonary Tuberculosis followed by other.

HIV infection increases the likelihood that new infection with M. tuberculosis (due to immune suppression) will progress rapidly to TB disease. However, ongoing medical care allows for the effective prevention or early diagnosis and treatment of these infections. WHO recommends that people with TB/HIV complete their TB therapy prior to beginning ARV treatment unless there is high risk of HIV disease progression and death during the period of TB treatment (i.e. a CD4 count <200/mm3 or the presence of disseminated TB).

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