II. Background: Natural History of HIV Disease

  1. Total duration from initial HIV Infection to AIDS
    1. No treatment: 10 years
    2. Early Antiretroviral therapy: May approach normal Life Expectancy
  2. Active immune response after infection: 2.1 months
  3. Primary infection usually asymptomatic
    1. Acute Retroviral Syndrome in 30-50%
  4. Initial infection with single Genotype
    1. Evolves into 15-20 distinct viral variants
  5. Virus gains access to CD4 cells via sequential binding
    1. CD4 receptor via sequential binding with CD4 receptor in combination with CCR5 or CXCR4 co-receptors
  6. Over time:
    1. CD4 cell numbers decrease
    2. Viral concentrations increases

III. Background: CD4 Count Related Disease progression

  1. Kaposi's Sarcoma, Dementia: 275 CD4 cells
  2. Non-Hodgkin's Lymphoma: 200 CD4 Cells
  3. Pneumocystis carinii Pneumonia: 150 CD4 Cells
  4. Mycobacterium Avium Complex: 100 CD4 Cells
  5. Toxoplasmosis: 50 CD4 Cells

IV. Staging: General

  1. Stage 1: CD4 500 Cells/mm3 or more
  2. Stage 2: CD4 200 to 499 Cells/mm3
  3. Stage 3: CD4 <200 Cells/mm3 or AIDS-Defining Illness

V. Staging: Early disease (CD4 Count > 500 cells)

  1. Presentation
    1. No symptoms
    2. May show mild Lymphadenopathy
  2. Management
    1. Early Antiretroviral therapy is recommended for all stages of HIV
    2. Previously, asymptomatic patients in this stage received no therapy
  3. Course over following 18-24 months
    1. Risk of occult infection or death: <5%
    2. Slow decline in CD4 Counts (40 to 80 cells/year)

VI. Staging: Intermediate Disease (CD4 Count 200 - 500 cells)

  1. HIV related disorders
    1. Thrush
    2. Pronounced Vaginal Candidiasis, Onychomycosis
    3. Recurrent Herpes Simplex Virus Infection
    4. Recurrent Varicella Zoster Virus Infection
    5. Pruritic Folliculitis
    6. Recurrent Bacterial Infections
    7. Mycobacterium tuberculosis
    8. Anogenital ulcers or warts
  2. Complications
    1. Pneumocystis carinii Pneumonia
      1. Atypical in this stage
    2. Kaposi's Sarcoma
    3. Non-Hodgkin's Lymphoma
  3. Management
    1. Antiretroviral therapy is continued from prior stages
  4. Course (Untreated) over following 18-24 months
    1. Risk of occult infection or death: 20-30%
    2. Treatment reduces risk by 2-3 fold

VII. Staging: AIDS Late Symptomatic Disease (CD4 50-200 Cells)

  1. Complications
    1. Development of Occult Infections
  2. Management
    1. Pneumocystis jiroveci prophylaxis (when CD4 Count <200 cells/mm3)
    2. Toxoplasmosis prophylaxis when CD4 Count <100 cells/mm3
    3. Antiretroviral therapy continues
  3. Course (Untreated) over following 18-24 months
    1. Risk of occult infection or death: 70-80%

VIII. Staging: Advanced Disease (CD4 Count < 50-100 cells)

  1. Complications
    1. Disseminated Mycobacterium Avium Complex
    2. Cryptococcal Meningitis
    3. Cytomegalovirus retinitis
    4. Cryptosporidiosis
    5. Disseminated Histoplasmosis
    6. Progressive Multifocal Leukoencephalopathy
    7. Primary CNS Lymphoma
    8. AIDS Dementia
  2. Routine Management
    1. Anti-Pneumocystis carinii prophylaxis
    2. Antiretroviral Management
    3. Anti-Mycobacterium Avium Complex prophylaxis
      1. Start at CD4 Count < 50 cells/mm3
    4. Screen for CMV Retinitis
      1. Ophthalmology exam every 6 months
  3. Course
    1. High likelihood of Occult Infection or death

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