Human Immunodeficiency Virus

(HIV 101)

Louie Mar Gangcuangco, MD, MSc, AAHIVS

Assistant Professor of Medicine, JABSOM
Principal Investigator, Pacific AIDS Education & Training Center –
Hawaii and US-affiliated Pacific Islands

July 17, 2024

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Disclaimer
The views and opinions expressed in this presentation are not necessarily those of the
Pacific AIDS Education & Training Center (Pacific AETC) or its eight local partner sites in HRSA Region
9, the Regents of the University of California or its San Francisco campus (UCSF or
collectively, University) nor of our funder the Health Resources and Services Administration (HRSA).
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The Pacific AETC is supported by the Health Resources and Services Administration (HRSA)
of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $4,377,449.
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an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
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Trade Name Disclosure Statement​
Funding for this presentation was made possible by 5 U1OHA29292‐08‐00 from
the Human Resources and Services Administration HIV/AIDS Bureau. The views expressed do
not necessarily reflect the official policies of the Department of Health and Human Services nor
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for training and identification purposes only.

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Learning Objectives
By the end of this training participants will be able to…
 Explain why someone should get tested for HIV

 Discuss the HIV life cycle in relation to how the available

therapies work.

 Describe the importance of linkage to care when someone

tests positive for HIV

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HIV and AIDS Statistics

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WHO HIV Epidemic 2023 estimates

World Health Organization. HIV data and statistics. Accessed Feb 19, 5
2024.
HIV Statistics

At year-end 2021, an estimated 1.2 million people in the United States

aged 13 and older had HIV in the U.S.

Estimated new HIV infections in the U.S.: 32,100

Lifetime treatment cost of an HIV infection is currently estimated at

$379,668 in 2010 dollars.

World Health Organization & CDC data 6

Diagnosed HIV cases (all stages) by county, 1983-2021

Hawaii State Dept of Health

https://health.hawaii.gov/harmreduction/files/2022/12/HIV-surveillance-annual-report-yea
r-ending-2021.pdf
Accessed May 2023
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Stage 3 (AIDS) Classifications and Deaths of Persons with Diagnosed HIV Infection Ever
Classified as Stage 3 (AIDS), among Adults and Adolescents, 1985–2017
United States and 6 Dependent Areas
HIV Cases Peaked 1992-1993
Decline in Cases due in part to
Highly Active Anti-Retroviral
Therapy Available since 1996

CDC HIV Surveillance 2018

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention
Note:Deaths of persons with HIV infection, stage 3 (AIDS) may be due to any cause.

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 HIV and AIDS:
Overview of the Immune
System

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Human Immunodeficiency Virus (HIV) (1)
 HIV causes Acquired Immune
Deficiency Syndrome (AIDS)

 HIV attacks the immune

system, making it difficult for the
body to fight infections

 Without treatment, people with

HIV (PWH) will develop AIDS

 Treatment greatly delays

disease progression and
prevents HIV transmission
Image source: HIVinfo.NIH.gov 10
The immune system: body’s defense against infections

Image source: HIVinfo.NIH.gov

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Cells of the immune system

CD4
T cells

Image source: Ernst LM, et al. Nanomaterials 2021, 11(11), 2991 12

HIV and AIDS: what is the difference?

Image from https://www.prevention.nyc/what-is-the-difference-between-hiv-and- 13

aids/
How is HIV transmitted?
Transmitted via certain body fluid(s)
 Blood
 Semen
 Vaginal Secretions
 Breast Milk

These body fluids enter into the body via…

 Mucous Membrane in anus or vagina
 Blood-to-blood (Intravenous drug use; needlestick injury)
 Perinatal (In utero, during birth, breastfeeding)

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How is HIV not transmitted?
HIV+ people do NOT transmit the virus via…
 Saliva
 Sweat
 Tears
 Urine
 Feces
 Vomit

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HIV
Life
Cycle

Source: Clinical Info HIV.gov 16

Cell to cell transmission of HIV

Image from: Bracq L, ET AL. Front. Immunol., 19 February 2018 17

There is no cure for HIV due to
anatomical and cellular reservoirs

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Natural History of untreated HIV infection

Popoola and Awodele. Afr. J. Med. med. Sci. (2016) 45, 5 - 21

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 Examples of AIDS-Defining
Conditions

Source: AIDS Defining Conditions | NIH

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 Clinical Manifestations of HIV
Pneumocystis pneumonia Candidiasis

Tomar et al. Int J of Oral Care and Research,

Clin Med 2008;8:539–43 January-March (Suppl) 2018;6(1):31-35

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Clinical manifestations of tuberculosis

Alsayed & Gunosewoyo. Int. J. Mol. Sci. 2023, 24(6), 5202 22

HIV Testing

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Natural progression of untreated HIV infection

Popoola and Awodele. Afr. J. Med. med. Sci. (2016) 45, 5 - 21

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USPSTF HIV Screening
Recommendations*
Population Recommendation Grade
Pregnant The USPSTF recommends that clinicians A
persons screen for HIV infection in all pregnant
persons, including those who present in
labor or at delivery whose HIV status is
unknown.
Adolescents The USPSTF recommends that clinicians A
and adults screen for HIV infection in adolescents and
aged 15 to adults aged 15 to 65 years.
65 years
Younger adolescents and older adults who
are at increased risk of infection should also
be screened.

*current as of May 2024; Topic is being updated.

USPSTF. Final recommendation statement on HIV Screening. Available at:
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/human-immunodeficiency-
virus-hiv-infection-screening
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Accessed December 17, 2023.
Window period of various HIV tests

Image source:
https://www.hiv.gov/hiv-basics/hiv-testing/learn-about-hiv-testi 26
ng/hiv-testing-overview Accessed May 31
HIV Seroconversion Window Period
Different types of tests diagnose HIV at different
intervals post-infection
 Antibody tests – as early as 3 weeks; most by 12 weeks
via oral fluid or blood

 Antigen test – as early as 2 weeks; most by 6 weeks

via blood

 Viral Detection (HIV RNA) – as early as 7 days; up to 28

days via blood

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Case 1
A 25-year-old cisgender male comes in the clinic for routine HIV
testing. His last unprotected (condomless) sexual encounter was 1
week ago. The HIV status of the partner is unknown. His HIV
screening test comes back negative. The patient does not have any
symptoms and is feeling well. Aside from counseling the patient on
safe sex practices, what is the best advice?

a. Your HIV test is non-reactive (negative) and there is no further

follow-up needed
b. Your HIV test is negative and you need a repeat HIV test tomorrow
c. Your HIV test is negative and you need a repeat HIV test in a few
weeks
d. Any of the above

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Acute HIV Syndrome
 Common Symptoms
fever, fatigue, and rash
 Less Common Symptoms
headache, swollen lymph glands, sore throat, feeling
achy, nausea, vomiting, diarrhea, and night sweats

Similar to other illnesses (e.g. flu, COVID-19)

Only experienced by about ½ of the people newly infected

Only an HIV test can diagnose HIV

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Antiretroviral Therapy

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Effective Treatment Saves Lives

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HIV life cycle and targets of antiretroviral therapy

Illustration: Cognition Studio, Inc. and David H. Spach, MD. Available at:
https://www.hiv.uw.edu/go/antiretroviral-therapy/general-information/co 32
re-concept/all
 Antiretroviral Therapy (ART)

*Long-acting injectable ART is now available

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 HIV Attachment to CD4 Cells
(GP -120)

(GP-120 Direct
Attachment
(Capsid)
Inhib.)

(CD4 Directed
Post-
Attachment
Inhib.)

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Source: Clinical Info HIV.gov
Entry Inhibitors

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Source: Clinical Info HIV.gov
HIV Reverse Transcription

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Source: Clinical Info HIV.gov
HIV Integration

Source: Clinical Info HIV.gov 37

Protease
Inhibition

Source: Clinical Info HIV.gov 38

Examples of one pill once a day
antiretroviral regimen for HIV (1)

Source:2022 HIV Drug Chart. https://www.poz.com/pdfs/POZ_2022_HIV_Drug_Chart_high.pdf

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Examples of antiretroviral therapy
options for HIV
Long-acting injectable

Source:2022 HIV Drug Chart. https://www.poz.com/pdfs/POZ_2022_HIV_Drug_Chart_high.pdf

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Recommended Initial Regimens for Most
People with HIV (in alphabetical order)
 bictegravir/tenofovir alafenamide/emtricitabine (fixed-dose
combination)

 dolutegravir/abacavir/lamivudine (fixed-dose combination)

 only for individuals who are HLA-B*5701 negative and without chronic
hepatitis B virus (HBV) coinfection

 dolutegravir + (tenofovir alafenamide or tenofovir disoproxil

fumarate) + (emtricitabine or lamivudine)

 dolutegravir/lamivudine (fixed-dose combination)

 except for individuals with HIV RNA >500,000 copies/mL, HBV
coinfection, or when ART is to be started before the results of HIV
genotypic resistance testing for reverse transcriptase or HBV testing are
available. AIDS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the
Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health
and Human Services. Available at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-
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Antiretroviral Treatment (ART)
Clinical Goals
 Reduce viral load as much as
possible for as long as
possible
 Increase CD4 cell count
 Ensure medication adherence
to preserve ART options
 Preserve quality of life
 Reduce HIV transmission

https://clinicalinfo.hiv.gov/en/glossary/viral-suppression

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 U=U and "Treatment as Prevention"
has revolutionized HIV prevention and care

Sexual
partners
(does not apply
to injecting
drug use)

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Case 2
A 40-year-old cisgender female comes to the clinic to establish primary
care. She feels well and does not have any symptoms.
During the social history-taking, you learned that she has had multiple
sex partners in the past. She has never been tested for HIV. Physical
exam is unremarkable.
What is the most appropriate advice for the patient?

a. It is appropriate to screen you for HIV

b. You should not worry about HIV because you only had a few sexual
partners in the past
c. You should not worry about HIV because you are a cisgender female
d. You should not worry about HIV because your physical exam is
normal

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Case 2 (continued)
 HIV antibody test is reactive (positive)
 HIV RNA is 200,000 copies/ml
 CD4 T cell count is 450 cells/uL

What is the appropriate next step?

a. HIV treatment (antiretroviral therapy) is not necessary
because her CD4 is above 200 cells/uL
b. HIV treatment is appropriate and antiretroviral therapy
options should be discussed
c. It is a false positive result. Repeat HIV testing in 3
months.

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Key Concepts in HIV Antiretroviral Therapy [1]

 Antiretroviral therapy (ART) is recommended for all

persons with HIV to reduce morbidity and mortality and
to prevent transmission to others
 Initiate ART immediately (or as soon as possible)
after HIV diagnosis to increase the uptake of ART and
linkage to care, decrease the time to viral suppression,
and to improve the rate of virologic suppression
 When initiating ART, it is important to educate patients
regarding the benefits of ART

AIDS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the
Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health
and Human Services. Available at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-
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Key Concepts in HIV Antiretroviral Therapy [2]
 Medications from at least 2 different classes are combined
to construct an antiretroviral regimen.
 Never give only one medication as it promotes HIV
resistance.
 HIV drug resistance testing is recommended at entry into
care for people with HIV to guide selection of antiretroviral
regimen.
 Treat all patients with hepatitis B.
 Selection of a regimen should be individualized:
 based on virologic efficacy, potential adverse effects,
childbearing potential and use of effective contraception, pill
burden, dosing frequency, drug–drug interaction potential,
comorbid conditions, cost, access, and resistance-test results
AIDS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the
Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health
and Human Services. Available at https://clinicalinfo.hiv.gov/en/guidelines/adult-and-
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HIV Care Continuum

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Linkage to HIV Care: Main Goals

Budak JZ. Linkage to HIV Care. Available from the

National HIV Curriculum (online). Accessed Feb 19, 2024 49
The HIV Care Continuum

 The HIV care continuum is a public health model that

outlines the steps or stages that people with HIV go
through from diagnosis to achieving and maintaining viral
suppression
U.S. DHHS
https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum/ 50
Accessed May 2023
US HIV Care Continuum, 2019

U.S. DHHS
https://www.hiv.gov/federal-response/policies-issues/hiv-aids-care-continuum/ 51
Accessed May 2023
HIV Care Continuum in Hawaii (Year 2020)

Hawaii State Dept of Health

https://health.hawaii.gov/harmreduction/files/2022/12/HIV-surveillance-annual-report-yea
r-ending-2021.pdf
Accessed May 2023
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The 95-95-95 Targets to end the HIV Epidemic

Image from: Together! Act Now | UNAIDS

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Delayed Linkage to Care: Key
Factors
 substance use
 lack of medical insurance
 lack of access to primary care prior to HIV diagnosis
 residence in a high-poverty area

Budak JZ. Linkage to HIV Care. Available from the

National HIV Curriculum (online). Accessed Feb 19, 2024 54
Aging with HIV (2021 Data)
 According to the Centers for
Disease Control and Prevention,
in 2021, of the nearly 1.1 million
people with diagnosed HIV in the
United States and dependent
areas, over 53% were aged 50
and up.
 People aged 50 and older
accounted for 16% of the
36,136 new HIV diagnoses in
2021 among people ages 13 and
older in the United States and
dependent areas.

HIV.gov ‘Aging with HIV’ website Accessed April 2024

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Aging &
HIV

ART Cohort Collaboration. Lancet HIV 2017:4 e354.

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Factors Contributing to Immune Activation & Inflammation

Abbreviations: ART, antiretroviral therapy; CMV: cytomegalovirus; ETOH, ethanol/alcohol; HBV, hepatitis B
virus; HCV, hepatitis C virus;

Babu H, et al. Front. Immunol., 26 August 2019 57

Spectrum of HIV Complications

Image from:
https://www.publichealth.org/public-awareness/hiv-aids/ 58
Summary
 HIV is a virus that attacks the immune system, causing a
decrease in CD4 T helper cells.
 There is currently no cure for HIV but effective treatment
with combination antiretroviral therapy saves lives
 U=U means that people with HIV who achieve and
maintain an undetectable viral load—the amount of HIV
in the blood—by taking antiretroviral therapy (ART) daily
as prescribed cannot sexually transmit the virus to others.
 Multidisciplinary approach is needed to strengthen the
HIV care continuum

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Resources for Further Learning
 HIVInfo - an online resource offering up-to-date HIV/AIDS
information to the general consumer, people with HIV/AIDS, people
recently diagnosed and those who care for them.
 The Body – basics on HIV, especially helpful for newly diagnoses
 POZ – breaking down stigma and empowering HIV+ people
 Positively Aware drug guide - HIV Medication Guide, updated yearly
 HIV.gov – general info about HIV from the US federal government
including national strategies and initiatives
 HIVE – safe conception and sero-discordant relationship information
 Please PrEP Me – information on staying HIV negative

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Questions?

Presenter: Louie Mar Gangcuangco, MD

louiemag@hawaii.edu

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