Barbara Clark-Alexander, RDH, BS, MPH, PhD

HIV/AIDS Update for Dental Professionals

AGENDA

INTRODUCTION HISTORY/WORLDWIDE IMPACT/TRENDS DEFINITIONS/IMMUNOLOGY/SPECTRUM TRANSMISSION HIV TESTING STATISTICS HIV/AIDS and DENTAL DISEASE MEDS LEGAL/ETHICAL ISSUES

Introduction

HIV vs AIDS Chronic infectious disease ANYONE can become infected as a result of a behavior Seeing more MSM, bisexual males; minority female heterosexual tx There still is no cure

History of HIV/AIDS in US

1959 - first evidence of AIDS documented from preserved tissues June 1981 - first cases of AIDS were reported in the US 1982 - disease became known as AIDS 1984 - causative agent was identified 1985 - blood test for antibodies to the virus became available; e.g. 48 Hours - panel

History of HIV/AIDS in US

1988 FL passed Omnibus AIDS Act 1990 Ryan White CARE Act 1993 AIDS case definition expanded; women recognized 1995 ACTG 076 1996 Govt. tried to mandate voluntary testing of pregnant women >95% 2002 New combination drug therapies 2012 First rapid oral fluid home test

What is HIV?

HIV is a retrovirus
HIV

genetic info is stored on RNA, not DNA To replicate, HIV uses an enzyme, reverse transcriptase, to convert RNA to DNA

Stages of Reproduction

HIV enters a CD4 cell Converts RNA to DNA HIV DNA enters nucleus of CD4 cell & inserts itself into cells DNA and instructs the cell to make copies of the original virus New virus particles leave cell, ready to infect other CD4 cells

Immunology

During HIV infection, 5% of CD4 cell population is being destroyed and replicated each day Early in the infection, the immune system may clear out the HIV cells When too many CD4 cells die, HIV virus takes over; inc. viral load Immune system weakens and AIDS defining diseases take over

Disease Spectrum

From infection until life-threatening conditions begin to develop is 10-15 yrs AIDS diagnosis to death was often <3 yrs CDC changed AIDS definition Homosexual men to IDU to infants to children to women to youth to. Now: traditionally underserved and hard-to-reach populations:

new infections in male adolescents & adults disease of minority women esp. teens;

Transmission

Any type of sexual contact

Including oral sex

Mostly blood-to-blood Infected female to unborn or newborn child -----Occupational exposure

NOT Transmitted

Through casual contact with people, places, things

Fluid Transmission

YES
Vaginal Semen Breast

Secretions

Milk

NO
Saliva Sweat Tears Urine Nasal

fluids

Pre-exposure Prophylaxis (PrEP)

Released 7/13/11
Botswana study: Truvada + Partners PrEP Kenya/Uganda study: Viread and Truvada reduced tx among serodiscordant couples by 63% CDC (iPrEx-2010) study showed that PrEP reduced HIV transmission among MSM by 73% Provide the first evidence that a daily oral dose of antiretroviral drugs used to treat HIV infection Can significantly reduce HIV tx among MSM and heterosexuals
CDC

ADHERENCE IS KEY

Transmission to Health Care Workers

Through 12/01, 57 HCW are known to have been occupationally exposed to HIV; no confirmed cases have been reported since 1999. Assume that all patients are infected Wear PPE STANDARD PRECAUTIONS must be used Immediately wash hands Careful handling/disposal of needles

Post-Exposure Prophylaxis (PEP)

Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis2 (September 30, 2005): Occupational exposure: Urgent medical concern Begin PEP ASAP after exposure hrs rather than days re-evaluation after 72 hrs. follow-up testing at 6 wks, 12 wks, 6 mo manage drug toxicity

HIV Testing

Antibody tests: ELISA

Screening tests for HIV antibodies Confidential or anonymous County Health Departments, MDs offices Looks for HIV (DNA particles) in recently infected who do not yet have detectable antibodies Confirmatory Tests: Western Blot, PCR 20-30 minutes; screening; Not confirmatory OraQuick ADVANCE Rapid HIV-1/2 Antibody Test

Antigen tests

Rapid HIV tests

Epidemiology of HIV/AIDS in US as of 2011

2011: US Reported AIDS Cases by Top 10 States/Dependent Area/Rate

State/Dep Area Wash DC GA MD LA NY FL US Virgin Islands MS Puerto Rico DE Rate/100,000 82.5 22.8 22.1 18.4 18.4 18.1 13.9 13.4 13.1 11.6

Florida Epicenters in Order of Prevalence, 2012

Miami (Dade) Fort Lauderdale (Broward) Jacksonville (Duval) Orlando (Orange) Tampa (Hillsborough) West Palm Beach (Palm Beach)

Worldwide Epidemic

2006 39.5M living with HIV

17.7M women 2.3M children <15 years Africa

2011 34M
3.3M 23M

4.3M new HIV infections

530,000 children

2.9M died of AIDS 1.2M >15M children worldwide have lost one or both parents to HIV/AIDS

Why are We Sending All

That Money to Africa?
2010: Its Working!!!!!

FACTS

HIV is the leading cause of death worldwide among ages 15-59 Epidemic is considered a threat to the economic well-being, social, and political stability of many nations.

Multi-Sectoral Impact of AIDS

Affects development, economic growth, households, individuals Workforce skilled workers lost Education teacher shortages; school absences Healthcare inc. demand for services is overwhelming public health infrastructures Military countries need protection

Multi-Sectoral Impact of AIDS

Malnutrition, food insecurity, famine Demographic effects

Alters population structures

Growth, mortality rates Age, sex distributions Fewer working age people, women

Multi-Sectoral Impact of AIDS

Life Expectancy
Reversing steady gains made during last century By 2010, <40 years in highlyaffected countries

AIDS Orphans

2006: 15M 2009: 16M (expected 25M)

World Trends: 2009, 2011

Sub-Saharan Africa
25.8 M living with HIV/AIDS 68% of persons with HIV/AIDS worldwide South Africa hardest hit Swaziland highest prevalence rate in world (1 in 3 adults); >40% among pregnant women Zimbabwe 1 in 4 adults 2009-2011: Sexual behavior changed in most countries reducing incidence 2004-2009: 24% in perinatal tx 19% in deaths 15 y.o.

World Trends

Asia 8.3 M
India 2nd highest # of people living with HIV/AIDS 5.1 M China 650,000; 44% IDU

Latin America & Caribbean >2 M Eastern Europe & Central Asia 1.6 M
Mostly

young people IDU & heterosexual transmission

World Trends

HIV prevalence is increasing

Ukraine,

Russian Federation
epidemic in all of Europe

Biggest

China
Some

African countries

World Trends

Women are becoming increasingly infected

1997: 41% of adults 2006: 48% 2009: 52%

Gender inequalities inc. vulnerability to HIV

Social, economic status, access to prevention & care services, sexual violence Women are biologically more susceptible

World Trends

Multiple effects on HIV+ women

caring for sick family members loss of property if widowed, infected may become impoverished violence when HIV status discovered

World Trends

Teens and Young Adults

Mostly girls and young women Account for half of new HIV infections 75% of HIV+ young people in SubSaharan Africa are girls 12M orphans in Sub-Saharan Africa

e.g. Kenya

>15M AIDS orphans worldwide

HIV/AIDS & Dental Disease

HIV disease is associated with a variety of problems in the head and neck region; as many as 70% of HIV-infected patients eventually develop such conditions.

Diseases Seen in Patients with HIV/AIDS

Gingivitis & Periodontal Disease Oral Candidiasis Hairy Leukoplakia Kaposis Sarcoma Herpes Simplex Herpes Zoster Non-Hodgkins Lymphoma

GINGIVITIS & PERIO DISEASE

Aggressive gingivitis & p.d. common in HIV+ In pts. with advanced disease, progresses rapidly from mild gingivitis to necrotizing process with severe pain, soft tissue loss, gingival recession, bone exposure and sequestration. Treat with oral antibiotics that target anerobic organisms (clindamycin, metronidazole) Diligent oral hygiene with frequent antibacterial mouth rise Topical irrigation with betadyne, chlorhexidine

ORAL CANDIDIASIS

Thrush Most common oral condition Tender, white, pseudomembranous or plaque-like lesions with underlying erosive erythematous musosal surfaces Angular chelitis Treat with topical nystatin (Mycostatin), oral troches of clotrimazole, systemically with ketoconazole

CANDIDIASIS

HAIRY LEUKOPLAKIA

White, vertically corrugated lesion along anterior lateral border of tongue Occurs almost exclusively in HIV+ patients Assoc. with rapid progression to advanced HIV disease (AIDS) Assoc. with Epstein-Barr virus (EBV) Usually asymptomatic Treatment is generally unnecessary

HAIRY LEUKOPLAKIA

HAIRY LEUKOPLAKIA

KAPOSIS SARCOMA

Most common malignancy Occurs in 43% of homosexual/bisexual men with advanced disease Typical lesion is pink/purple, not tender, macular or slightly raised or nodular on cutaneous and mucosal surfaces Treatment with local/systemic chemotherapy and radiation

KAPOSIS SARCOMA

Non-Hodgkinss Lymphoma

2nd most common malignancy in AIDS pts. Appears after KS and OIs Fever, night sweats, weight loss Usually a grim/prognostic sign Large fungated/ulcerated extremely painful mass, or large ulcerative area, and may be mistaken for giant aphthous lesion Treatment is with aggressive systemic chemotherapy

APHTHOUS ULCER

Lesions may be small, or small ulcers coalesce into large ones that present anywhere in oral cavity or pharynx Giant lesions more common in HIV+ Cause tremendous morbidity
Anorexia Dehydration AIDS

wasting, weight loss

Nutrition therapy; topical corticosteroids

APHTHOUS ULCER

ORAL HERPES SIMPLEX

Frequently assoc. with HIV disease HSV-1, HSV-2 (herpes labialis most common presentation) Crops of fever blisters, on palate, gingiva, other oral mucosal surfaces Lesions larger, more numerous, recur more frequently, persist longer Treat with oral acyclovir; large lesions with IV acyclovir (Valtrex, Zovirax)

HERPES

Herpes Zoster

Can be a sign of decreasing cellular immunity associated with progression of HIV disease More common in HIV+, than HIV neg. Treat with acyclovir and analgesics but with higher doses than for herpes simplex If oral therapy fails, use IV acyclovir Lesions in patients with advanced HIV disease may persist up to 10 months despite aggressive therapy

Some Treatment Meds

Entry Inhibitors Fusion Inhibitors Reverse Transcriptase Inhibitors

Entry Inhibitors

SelzentryTM (FDA 2007), maraviroc Binds to a protein on HIV's surface so HIV cannot successfully bind with the surface of T-cells (CD4), thus preventing the virus from infecting healthy cells. Doesnt allow HIV cells to bind to CD4 cells Virus does not enter CD4 cell, so it cannot replicate!

Fusion Inhibitors

Fuzeon (FDA 3/03) Stops entry into CD4 cell nucleus Virus does not enter CD4 cell nucleus, so it cannot replicate!

2008: INTELENCE

New salvage drug for adults Etravirine non-nucleoside reverse transcriptase inhibitor (NNRTI) Sustiva (FDA 1998), efavirenz Blocks enzyme (reverse transcriptase) so RNA does not become DNA Must be taken with other anti-HIV meds

The Best Prevention

Standard (Universal) precautions Take meds to reduce viral load(s) Abstinence/monogamy/precautions

Condoms Drug and alcohol use

Vaccine-related research Drug therapy trials

Legal Issues

Confidentiality Noncompliant carriers Informed consent Employment HIV has been a reportable condition in Florida since July 1997 and in U.S. since July 2005

Ethical Issues

Is it an ethical obligation to care for clients with HIV? Why are persons with HIV/AIDS still treated differently than those without the disease? Does changing the classification to chronic disease change perceptions?

The Next Step

MAKE INFORMED CHOICES when it comes to behaviors that put you at risk for HIV infection PROFESSIONAL RESPONSIBILITY to respond in reasonable ways to those with HIV infection and/or AIDS

Resources

CDC WHO State of Florida HIV/AIDS Surveillance Data NY State DOH

Persons living with HIV/AIDS

Thank You Ladies & Gentlemen

Oral Diseases of HIV vs AIDS

Oral Candidiasis
HPV Oral warts Human Papillomavirus Herpes Simplex Virus

Oral Candidiasis
Hairy Leukoplakia Epstein-Barr Virus Kaposis Sarcoma Intraoral, skin, visceral, lymph node lesions Lymphoma
non-Hodgkins Lymphoma

Herpes Zoster -Varicella Virus

Salivary Gland Enlargement HIV-G

HIV-P