THE UNIVERSITY OF NORTH CAROLINA CHAPEL HILL

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					           THE UNIVERSITY OF NORTH CAROLINA – CHAPEL HILL
               AIDS: PRINCIPLES, PRACTICES AND POLITICS
                             Course Syllabus
                              Spring 2008

COURSE NUMBERS:

         PUBH 420          (Section 1 – Undergraduates)
                           (Section 2 – Graduate, Law & Continuing Studies)
         DPET 810          School of Pharmacy
         DENT 482E         School of Dentistry
         MEDI 483          School of Medicine
         NURS 414          (Section 1) School of Nursing


COURSE FACULTY:

         Ronald P. Strauss, DMD, PhD                            966.2788           ron_strauss@unc.edu
         Course Director
         School of Dentistry

         Charles van der Horst, MD                              966.2536           cvdh@med.unc.edu
         Co-Course Director
         School of Medicine

         Amanda Corbett, PharmD                                 843.2280           ahcorbet@email.unc.edu
         School of Pharmacy

         Ann Jessup, PhD, RN, CFNP                              966.8561           ajessup@email.unc.edu
         School of Nursing

         Suzanne Maman, PhD                                     966.3901           maman@email.unc.edu
         School of Public Health


TEACHING ASSISTANT:               Jeff Edwards, MSW             966.4690           Jeff_Edwards@dentistry.unc.edu

MEETING TIME & PLACE:                Carroll Hall, Room 111
                                     Tuesday: 5:30PM - 6:50PM
                                     Lectures & Panel Discussions, Questions and Answers


PREREQUISITES:             None. Open to undergraduate, graduate and professional students.


COURSE CREDIT:             1 Credit.

This course is offered with the support of the UNC Center for Health Promotion and Disease Prevention, the Office of the
Vice Provost of Health Affairs, the UNC Center for AIDS Research (Grant # P30 HI50410), and The UNC-CH Schools of
Dentistry, Medicine, Nursing, Pharmacy and Public Health.




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         AIDS: PRINCIPLES, PRACTICES AND POLITICS - SPRING 2008 SCHEDULE OF CLASSES

Date                                    Topic                                   Speaker
1/15/08                HIV: The Virus & the Immune System          Charles van der Horst, MD
                                                                   UNC Div. of Infectious Diseases
                                                                   cvdh@med.unc.edu

1/22/08                Face of AIDS: Patient Panel                 Ronald Strauss, DMD, PhD
                                                                   UNC Dept. of Dental Ecology
                                                                   ron_strauss@unc.edu

1/29/08                International AIDS, Prevention Strategies   Myron S. Cohen, MD
                                                                   UNC Div. of Infectious Diseases
                                                                   MSCohen@med.unc.edu

2/05/08                Substance Use and Interventions             Wendee Wechsberg, PhD
                                                                   Research Triangle Institute
                                                                   wmw@rti.org

2/12/08                HIV: Manifestations of Disease              Charles van der Horst, MD
                                                                   UNC Div. of Infectious Diseases
                                                                   cvdh@med.unc.edu

2/19/08                Prevention 101: Condom…show and             Peter Leone, MD
                       Tell plus Youth and Teens at Risk           UNC Div. of Infectious Diseases
                                                                   PAL007@med.unc.edu


2/26/08                HIV: Young Women in South Africa            Audrey Pettifor, PhD
                                                                   UNC Dept. of Epidemiology
                                                                   apettif@email.unc.edu

3/4/08                 Film “A Closer Walk”                        Film (120 minutes)
                       (Alternate showings possible)               Bring popcorn! 5:30-7:20

3/11/08                SPRING BREAK

3/18/08                HIV in the Prison Setting                   David Wohl, MD
                                                                   UNC Div of Infectious Diseases
                                                                   wohl@med.unc.edu


3/25/08                Gay Life in America                         David Jolly, PhD
                                                                   North Carolina Central University
                                                                   DJolly@nccu.edu

4/01/08                HIV in the African American Community       Adaora Adimora, MD, MPH
                                                                   UNC School of Medicine
                                                                   adimora@med.unc.edu

4/08/08                Tuberculosis and HIV                        Annelies van Rie MD, PhD
                                                                   UNC School of Public Health
                                                                   vanrie@email.unc.edu

4/15/08                AIDS and Mental Health                      Glenn Triesman, MD
                                                                   Johns Hopkins School of Medicine
                                                                   Glenn@jhmi.edu

4/22/08                Interactive Theatre Carolina                Ben Saypol, MA
                                                                   UNC Campus Health Services
                                                                   saypol@unc.edu
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COURSE DESCRIPTION

This course offers participants a multi-disciplinary perspective on acquired immunodeficiency syndrome
(AIDS) -- its etiology, immunology, epidemiology and impact on individuals and society. How AIDS is
framed by a society determines not only how sick persons are treated by the degree to which the rights of
the individual are upheld.

GOAL: To understand the complexity and multi-dimensionality of the evolving phenomenon known as
AIDS as a paradigm for the relationship between disease, society and public policy.

COURSE OBJECTIVE: (See below for specific objectives for each class topic).

Upon completion of this course, the student will be able to:

          1. Identify the syndrome of AIDS by describing the etiology, epidemiology, clinical disease
             manifestations and treatments.

          2. Demonstrate a conceptual understanding of the syndrome by describing how society has framed
             this disease, the historical background, and the legal and ethical issues associated with it.

          3. Demonstrate an understanding of disease implications for HIV-infected people, AIDS patients
             and their families by describing psychological considerations.

          4. Demonstrate an understanding of disease implications for society, by describing infection
             control measures, contact tracing, education, economics, community resources, the stress of
             care-giving and prospects for the future.

                                       COURSE REQUIREMENTS

ESSAY: A two-page essay on one of the following topics is required and must be turned in at the
beginning of class on April 08. Papers must be typed, double-spaced, with 12 point type and one inch
margins:

Topics:           1. Select a serious problem directly related to HIV/AIDS and discuss facilitators and
                     barriers to its resolution.

                  2. Select an issue from the course and discuss how it will/does affect persons engaged in
                     your career/profession. Characterize how your profession is and should be responding
                     to this issue.

                                              ATTENDANCE

Attendance at each class is required and will be recorded by signatures on attendance cards which will be
collected at the end of class. The UNC Honor System will be applied to all student signatures given as
verification of attendance. Students are not permitted to fill out or turn in an attendance card for another
student and doing so will be treated as an Honor Code violation.

Students arriving more than 15 minutes after a lecture has started will be considered absent. Students who
arrive after a speaker has begun are asked to enter quietly via the rear door of the room to avoid disturbing
the lecture.

Students who are disruptive or distracting (no reading DTH or Vogue, etc.) during class will be asked to
leave. This will be recorded as a missed class. The attendance cards of students leaving class early will not
be accepted.


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The first class of the semester does not count for an absence if it is missed.

One absence will be allowed without penalty, provided that this absence is not the last day of class
(required attendance – no exceptions). Students may make up one additional absence with an alternative
assignment. Greater than two absences will result in a grade of F for the course.

To make up for an absence, students must write a 5-page paper focusing on the topic missed in lecture.
The 5-page paper must be accompanied by a separate list of resources or references used. The make up
assignment should be submitted to the Teaching Assistant within 2 weeks after the missed class and include
student’s name, PID, email address and date of class missed. Students are NOT required to document or
explain their second absence, just to make it up.

Anyone with more than 2 absences (not including the first class of the semester) needs to make an
appointment to meet with the course director, Dr. Ron Strauss.

                                                  GRADING

The course is mandatory PASS/FAIL for all undergraduate and continuing studies students enrolled in
PUBH 420 - Section 1; and all professional school students enrolled in DENT 482E; MED 483; NURS 114
- Section 1; and PHPR 133 - Section 2. Satisfactory completion of the essay and attendance requirements
will result in a grade of PASS.

Graduate, law and post-graduate continuing studies students enrolled in PUBH 420 - Section 2 will be
graded on the standard system for their program. Satisfactory completion of the essay and attendance
requirements will result in a grade of P or B. To achieve a grade of H or A, students in this section must
complete a 20-page research paper with 20 or more references that is a critical analysis of one of the
significant issues directly related to HIV/AIDS that was presented in class. Students wishing to pursue this
option must inform the teaching assistant in writing or by e-mail of this intent by February 15 with a brief
(several sentences) statement of the proposed topic. This paper, in lieu of the essay, is due at the beginning
of class on April 12. Topic must be approved by a course director.




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                       AIDS COURSE CLASS OBJECTIVES -SPRING 2008

HIV: THE VIRUS AND THE IMMUNE SYSTEM                                                     January 15, 2008
At the end of class, the student will be able to:
     State the structure and function of the various parts of the immune system
     Describe the process of HIV infection at the cellular level
     Describe how HIV affects the immune system.


FACE OF AIDS: PATIENT PANEL                                                               January 22, 2008
At the end of the class, the student will be able to:
     Describe health care system changes identified by the panel to meet the needs of the HIV infected
        patient
     Identify support services that HIV+ patients feel would help them to maintain a “normal” lifestyle
     State the factors that HIV+ patients consider most and/or least helpful in living with AIDS.


INTERNATIONAL AIDS: PREVENTION STRATEGIES                                               January 29, 2008
At the end of class, the student will be able to:
     Compare the incidence/prevalence and transmission of HIV disease within the United States to
        those worldwide
     Compare the efforts to control the spread of HIV disease outside the United States to those within
        the United States
     Describe the major issues facing persons living with AIDS in countries such as Africa.


SUBSTANCE USE AND INTERVENTIONS                                                         February 05, 2008
At the end of class, the student will be able to:
     Describe the influence of intravenous drug use and crack use on the spread of HIV disease
        worldwide and especially in the United States
     Describe the influence of HIV disease within the drug-using community
     Identify the variation in the clinical manifestations of HIV disease among HIV+ drug users
     Describe the phases of drug use and what addiction is
     Identify the main substances used by substance abusers and describe their routes of administration
     Describe the treatment modalities used for substance abusers and the problems accessing treatment.


HIV: MANIFESTATIONS OF DISEASE                                                      February 12, 2008
At the end of the class, the student will be able to:
     Describe the screening procedure for HIV disease
     Describe the natural history of HIV disease
     State the early symptoms of HIV and some opportunistic infections which AIDS patients develop
     Describe some current treatment protocols of HIV disease


HIV PREVENTION 101: CONDOMS AND YOUTH AND TEENS AT RISK                                 February 19, 2008
At the end of the class, the student will be able to:
     Describe the epidemiology of HIV and STDs among teens
     Describe behaviors among teens that place them at risk for HIV infection
     Describe possible interventions to reduce risk for teens
     Describe the correct use of condoms.




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HIV: YOUNG WOMEN IN SOUTH AFRICA                                                      February 26, 2008
At the end of the class, the student will be able to:
     Describe the epidemiology of HIV infection in young women in sub-Saharan Africa
     Describe risk factors for HIV infection in young women in sub-Saharan Africa
     Have a general understanding of interventions being conducted to reduce new infections in young
        women in sub-Saharan Africa

“A CLOSER WALK” - VIDEO                                                            March 4, 2008
At the end of the class, the student will be able to:
     Identify personal issues faced by PLWAs in international settings.
     Describe the impact of stigma on the lives of PWLAs.
     Examine how varied cultures and societies deal with PWLAs in different ways.

SPRING BREAK                                                                            March 11, 2008

HIV IN THE PRISON SETTING                                                               March 18, 2008
At the end of the class, the student will be able to:
     Describe the epidemiology of HIV in prisons
     Describe unique problems of prevention and treatment in prisons
     Describe the impact of released prisoners on the community.

GAY LIFE IN AMERICA                                                                        March 25, 2008
At the end of class, the student will be able to:
     List critical factors that shaped the emergence of a gay identity in the United States
     Discuss the response of gay men in the U.S. to the AIDS epidemic and the impact of that response
        on HIV prevention services, treatment research, and care services
     Identify the psychosocial effects of the epidemic on gay men in the U.S.

AIDS IN THE AFRICAN AMERICAN COMMUNITY                                              April 01, 2008
At the end of class, the student will be able to:
     Identify the unique characteristics of the HIV epidemic among African-Americans
     Identify possible strategies in prevention efforts among African-Americans.

TUBERCULOSIS AND HIV                                                                    April 08, 2008
At the end of the class, the student will be able to:
     Describe the epidemiology and treatment of Tuberculosis and HIV
     Describe unique problems of prevention and treatment
     Describe the impact of Tuberculosis and HIV on the community.

AIDS AND MENTAL HEALTH                                                                April 15, 2008
At the end of class, the student will be able to:
     Describe the predictors of good psychological functioning in persons with AIDS
     Describe predictors of behavior change
     Describe the psychological barriers to behavior change among specific populations
     Describe psychosocial barriers to attempts to contain the spread of HIV
     Describe some of the psychiatric manifestations of AIDS.

“AND THE BAND PLAYED ON” – VIDEO                                                        April 22, 2008
At the end of the class, the student will be able to:
     Describe the history of how the HIV epidemic was noticed.
     Identify the key characters in the drama of the AIDS epidemic
     Describe the initial response of government and public health authorities.




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                                  FREQUENT TERMINOLOGY 2008

Acute HIV Infection-Also known as Primary HIV Infection this occurs when the patient is newly infected
and usually means that they have not yet developed antibodies to HIV and so their ELISA test is negative.
A diagnosis is made with an HIV PCR test is done.

AIDS (Acquired Immune Deficiency Syndrome) - A group of signs, symptoms, and diseases indicating
severe impairment of the immune systems caused by infection with the Human Immunodeficiency Virus
(HIV). It is transmitted through intimate sexual contact, in particular, anal and vaginal intercourse; direct
exposure to or infection with infected blood or blood products; and from an infected woman to her fetus or
infant. The data on oral sexual transmission are unclear. HIV infects cells with the CD4 protein on the
surface. Over a period of years, the number of these cells slowly decreases which impairs the immune
system. Once the immune system is impaired, persons who are diagnosed as having HIV infection may
easily develop one or more specific opportunistic infections or rare cancers which become life-threatening,
usually when the CD4 lymphocyte count is less than 200 cells/ul. Once they develop one of these
infections they are said to have AIDS. Of persons officially diagnosed as having AIDS for three or more
years, over 80 percent have died.

Specific diseases must be present to be diagnosed officially as AIDS and to be reported to the Centers for
Disease Control. These diseases are defined separately in the following section. In general, the diseases
include unusual forms of bacterial, fungal and viral infections as well as rare cancers.

AIDS Dementia - A degenerative disorder of the brain and central nervous system caused by infection
with HIV that leads to progressive deterioration of mental and neurological functions. AIDS dementia is
reported to occur in approximately 70 percent of AIDS patients with low CD4 counts. Symptoms include:
memory loss, mood shifts, depression, difficulty in concentrating, and motor impairment, including
difficulty walking and weakness in arms and legs.

Antibody - Special protein developed by the body's immune system in response to exposure to specific
foreign agents. A given antibody exactly matches a specific agent that causes an infection, much like a key
matches a lock; the antibody can help to destroy the infectious agent. The HIV test measures antibodies to
HIV proteins.

Antigen - A substance that stimulates the development of antibodies.

Antiretroviral Drug - A medication which inhibits retroviruses.

Asymptomatic - Without subjective or objective signs of illness. People who are infected with the AIDS
virus (HIV), as evidenced by the presence of HIV antibodies, may show no symptoms of disease.
Currently, scientists believe that 50 percent of persons who are infected with the HIV will develop AIDS
within 10 years if untreated.

B-Cells - White cells called lymphocytes which produce antibodies.

Below Detectable-A statement about the viral load. When a patients viral load (HIV RNA) drops below the
level at which the assay (PCR) is able to detect RNA.

Blood/Body Fluid Precautions - Special medical procedures taken to prevent infections transmitted by
direct or indirect contact with infectious blood or body fluids. Gowns should be used if it is likely that
clothing will be soiled by the infected blood or body fluids. Masks and goggles are used if there will be
splashes of infected material. Gloves are used if the health care professional comes into contact with or
handles blood or body fluids.

CD4-Lymphocyte - White cells that have the CD4 protein on their surface to which HIV binds. Normal
value is over 500 cells/mm3 . The number of these cells slowly decreases over time as HIV kills them.

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CD8 Lymphocyte - White cells that have a CD8 protein on surface. Their function is predominantly as
cytotoxic (cell killing) lymphocytes and are important for control of virus infected cells.

Cell Mediated Immunity - That part of the immune system that uses cells such as cytoxic lymphocytes
(CD8 cells) and natural killer cells to fight infections.

Clade- HIV-1 is categorized into major (M) and outlier (O) groups. Group M is further divided into
subtypes (clades) A-J. These subtypes have wide geographic diversity. Subtype B is most common in
North America and Europe whereas Subtype A and C are common to Africa and Subtype E occurs in
Thailand.

Contact Tracing - When public officials: 1) actively seek the names or trace the identity of persons who
have come in contact with or have been exposed to a communicable disease, and 2) actively notify these
contacts concerning their possible exposure to the disease. Contact tracing is most commonly associated
with certain contagious, highly infectious diseases, such as syphilis or other sexually transmissible diseases.

Contagious Disease - An illness caused by a specific infectious agent (i.e., a virus, bacteria, fungus) that is
transmitted, directly or indirectly, from an infected person to a susceptible host.

Controlled Clinical Trial - A clinical study in which two or more therapies are compared, and the decision
as to which patient receives which therapy is often determined by chance. Some of these studies involve a
"placebo," usually a pill that looks like the drug being studied but does not contain any active ingredients.
Such research is referred to as a "blind study" -- that is, the patient does not know which treatment he is
receiving. In “double blind” studies, neither the treating physician nor the patient knows what arm of the
study the patient is on.

Cytotoxic lymphocytes - A type of white cell that can kill cells infected with viruses or bacteria.

ELISA Test (Enzyme Linked Immunoabsorbent Assay) - A simple, rapid, sensitive blood test that
measures antibodies to HIV proteins. Plastic wells are coated with HIV proteins. The patients blood is
placed in the well and then washed off. Then antibodies directed at human antibodies are placed in the well.
If the patient has antibodies to HIV then they will stick (adhere) to the HIV proteins and the anti-antibodies
will then stick to the patients antibodies forming a sandwich: (HIV protein) + (Patient antibody) + (anti-
human antibody). The ELISA test was licensed by the Food and Drug Administration in 1985 to screen
blood supplies only. As a blood screening test, the ELISA is highly sensitive and produces a small number
of “False positive” and “false negative” test results. Because false positives are produced and the virus has
a long incubation period, ELISA's are usually repeated if the first test is positive. If the patient tests
positive a second time, then a more specific test, the Western Blot, is performed to confirm the results.

Endemic - The constant presence of a disease or infectious agent, like a virus, within a geographic area or
defined population. For example, HIV infection is estimated to be present in a large percentage of certain
well-defined groups and is now considered to be endemic in that population.

Enzyme - A protein made by cells or viruses that induces chemical changes or chemical reactions in other
substances without itself being consumed. Enzymes made by HIV include reverse transcriptase, protease
and integrase. Enzymes unique to the pathogen are good targets for medications.

Epidemic - When an illness or disease occurs in a region, population or community clearly in excess of
what is expected.

Epidemiology - The study of how disease or injuries are distributed in human populations and what factors
influence this distribution. People who conduct such studies, or epidemiologists, are concerned with: 1)
how disease patterns change over time: 2) how disease patterns differ by geographic area; and 3) what


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personal or societal characteristics influence the disease pattern. These characteristics may include
social/economic demographic factors (e.g., age, sex,
race, ethnic groups, income, education, social class, occupation); biological factors (e.g., different blood
characteristics); health behaviors (e.g., smoking, diet), and societal factors (access to care, public
transportation, plumbing, proximity to a toxic waste dump).

Exposure - When an individual has contact with HIV in a way that makes it possible to transmit the virus;
however, it is not clear if everyone who is exposed to HIV will be infected with it. Generally, it is believed
that numerous substantial exposures, such as a direct transfusion of contaminated blood or numerous sexual
encounters through anal intercourse are necessary or most efficient in transmitting the AIDS virus.

False Negative - When the test results from a diseased person fail to indicate the presence of the disease or
condition. With HIV infection, a false negative occurs when an HIV-infected individual fails to test
positive on any one of a series of HIV antibody tests - usually two ELISA's and a Western Blot.

False Positive - When the test results from a non-infected person indicates the presence of the disease or
condition. With HIV infection, a false positive occurs when a non-infected person tests positive on a series
of HIV antibody tests - usually two ELISA's and a Western Blot.

Fusion Inhibitor-A new class of antiretrovirals that block the binding of HIV to the CD4 cell. The first
such drug is T-20 or Fuzeon which must be given by subcutaneous injection.

HAART-Highly active antiretroviral therapy consisting of three or more drugs active against HIV.

Hairy leukoplakia - a mouth infection associated with HIV infection consisting of white patches on the
sides (lateral edges) of the tongue and caused by Epstein-Barr Virus (EBV).

Hemophilia - an inherited condition causing an abnormal clotting of blood, leaving the individual at risk of
severe or spontaneous bleeding. Hemophilia is treated by the infusion of blood clotting factors prepared by
pooling plasma from thousands of blood donors. Before screening was instituted, many hemophiliacs (70 -
90%) were infected by HIV-contaminated clotting factor in 1983. Current blood screening tests for HIV
have greatly reduced the risk of persons with hemophilia receiving contaminated blood products.
Furthermore, clotting factors used today are treated to eliminate HIV contamination. Hemophiliacs are no
longer considered at high risk for acquiring HIV infection if they are currently uninfected.

High-Risk Behaviors for AIDS - Characteristics or behaviors that increase one’s chances of acquiring
AIDS or HIV infection. Groups often noted as being "high-risk" or who practice "high-risk" behaviors
include:
     Homosexual and bisexual males;
     Persons who share needles and who inject drugs directly into their veins;
     Male and female prostitutes;
     Sexual partners of persons in high-risk groups;
     Infants born to women in high-risk groups; or
     Persons receiving blood transfusions or blood products between 1978-1985 when the screening for
         HIV antibodies began.

HIV Rapid Test-These are usually tests that are cheap, easy to perform and are used predominately in
resource limited settings such as sub-Saharan Africa. Often a drop of blood is placed on a piece of paper
which has HIV proteins in a band imbedded in it. The edge of the paper is then placed in a buffer or
solution which carries the antibodies if present in the blood up the paper where they can bind to the HIV
proteins causing a color reaction to occur. A color line appears if antibodies are present.

Human Immunodeficiency Virus (HIV) - The specific AIDS retrovirus which has been identified as
destroying the body's immune system (CD4 lymphocytes), making it susceptible to life-threatening,
opportunistic infections or rare cancers. The HIV-1 is believed to be a relatively new virus having crossed

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over from chimpanzees in the early part of the 20th century and HIV-2 from the Sootey Mangabey at about
the same time. HIV-1 is categorized into major (M) and outlier (O) groups. Group M is further divided into
subtypes (clades) A-J. It is particularly resistant to eradication, as the HIV genetic material is incorporated
into the healthy genetic material of the blood cells (CD4 lymphocytes) and is reproduced with those
chromosomes. Because the HIV genetic material is reproduced, individuals who are infected with the virus
remain carriers for the rest of their lives. Most people that are infected with the virus make antibodies to
the virus within three weeks of infection, but some may take as long as two months to become antibody
positive. In untreated people, half of them will take more than ten years to develop disease from the HIV
infection and half will get sick before that time.

HIV-2 - A retrovirus, identified by the Pasteur Institute in Paris, which has currently been isolated among
West Africans and a small number of AIDS patients in France, West Germany and Great Britain. The virus
is capable of causing clinical symptoms that are similar to those found in patients with AIDS and related
disorders but at a slower rate than HIV-1. This virus is strikingly similar to the Simian Immunedeficiency
Virus (SIV) from the Sootey Mangabey, a primate found in West Africa.

Humoral Immunity - That part of the immune system that combats infections using antibodies made by
B-cells.

Incidence - The number of new cases of a disease over a specified period of time divided by the population
at risk during that time period (e.g. the occurrence of new cases of a disease per person during the time
observed.)

Immune Recovery-The viral load in patients who are treated with 3 or more antiretroviral medications
often drops to undetectable levels (less than 50 or 400 copies/ml). When that happens the number of CD4
cells can increase dramatically, sometimes to normal levels. When that happens there is often recovery of
the immune system in that not only is the number higher but the cells work as well. Then the risk of
opportunistic infections decreases dramatically.

Immune System - A complex network of organs and cells that allows the body to defend itself against
infections and substances which are foreign to the body.

Infectious Disease - An illness that results from the entry, development or multiplication of a disease-
causing organism. Not all infectious diseases are highly contagious or easily communicable to other
people. Although HIV is highly-infectious, it is not easily or casually transmitted.

Informed Consent - When it is documented that a patient has been counseled by trained counselors about
the benefits as well as risks of undergoing a procedure and the patient agrees, in writing or verbally, to
undergo that procedure.

Integrase - Enzyme made by HIV which cuts host cell chromosomes and integrates HIV into the
chromosomes.

IVDU-Intravenous drug use.

Latency Period - The time period over which an infection exists without any symptoms appearing or the
time period from the point of infection to showing clinical signs of the disease. Based on current data, the
latency period for the HIV is estimated to range from ten to twelve years. During the latency period of HIV
infection, the person can transmit HIV.

Lipodystrophy Sydrome-This syndrome has been recently described in patients with HIV treated with
antiretroviral medications. The etiology of the syndrome is not known. It consists of some or all of the
following: loss of subcutaneous fat especially on the face, limbs and buttocks, development of fat in the
abdomen around the viscera, development of a buffalo hump between the shoulders, elevation of serum
cholesterol and triglycerides. Some patients on protease inhibitors also develop diabetes.

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Lymphocyte - White cells in blood which are important for fighting infection. Include B Cells, T Cells
(CD4, CD8), and Natural Killer Cells.

Macrophages - White cells derived from monocytes in blood. They can be infected by HIV, travel outside
the blood system and can serve as reservoirs of infection e.g. not killed by virus.

MSM-Men who have sex with men.

Mutation - A change in the genetic component of a human cell or virus (i.e., DNA or RNA) that can cause
the cell or virus not to produce proteins or can change the proteins that are made. HIV can mutate in the
presence of antiretroviral medications and become resistant to those medications so that they no longer are
effective in suppressing the virus replication.

Natural Killer Cells (NK) - Lymphocytes that kill virus infected cells.

Needle Stick Injury-Health care workers in the course of their work sometimes sustain a needle stick
injury in which a needle or scalpel which is contaminated with the blood of a patient cuts the health care
worker. The risk of transmission of HIV in these circumstances if the patient is HIV positive would be less
than 1 in 300. The main risk factors for transmission is if the needle is hollow bore (ie not a surgical suture
needle), if needle is stuck into the muscle of the health care worker, if the needle was in a vein or artery of
the patient and if the patient had a high viral load or AIDS.

Non-nucleoside Reverse Transcriptase Inhibitor (NNRTI)-This is a class of drugs that attach to the
reverse transcriptase, altering its shape (conformation) preventing it from copying the genetic material of
HIV. Three main drugs are approved: nevirapine (Viramuune), delavirdine (Rescriptor), efavirenz
(Sustiva). These drugs are generally well absorbed, widely distributed in the body and cheap to make. They
can cause rash and hepatitis. Resistance can develop to them with a single mutation.

Nucleoside Reverse Transcriptase Inhibitor (NRTI)-This is a class of drugs that is incorporated into the
elongating DNA chain copy of the HIV RNA made by the reverse transcriptase enzyme. Once incorporated
however, the next nucleoside can not be added hence this medications are often call “chain terminators”.
The commonly used medications in this class are zidovudine (AZT, ZDV or Retrovir), lamivudine (3TC or
Epivir), abacavir (Ziagen), didanosine (Videx or ddI), stavudine (Zerit or d4T). The related compound, a
nucleotide, is tenofovir (Viread). These compounds differ, one from another, with different side effects and
can produce different resistance mutations in HIV. AZT and 3TC have been combined into Combivir and
together with abacavir as Trizivir.

Opportunistic Infections - A variety of infections that occur in individuals who do not have healthy
immune systems. These diseases do not normally occur in healthy persons. Opportunistic infections can
occur in patients with AIDS (usually less that 200 CD4 lymphocytes), patients on immunosuppressive
medications for organ transplantation or patients with malignancies receiving chemotherapy.

Pediatric AIDS - Clinical AIDS in children under 13. Because more common or even rare congenital
infections and congenital immune-related diseases must be eliminated as a cause of illness, a working
definition of pediatric AIDS is open to more interpretation.

Polymerase Chain Reaction (PCR) - Method of amplifying (increasing) the quantity of small amount of
viral DNA or RNA so that it can be detected and measured.

Predictive Value - The likelihood that an individual with positive test results actually has the disease (i.e.,
is a true positive), or the likelihood that an individual with a negative test does not have the disease (i.e., is
a true negative). The predictive value of a positive test is equal to the number of true positive individuals
divided by the number of all positives identified. Because the HIV antibody tests were designed to be
highly sensitive and accurately identify as many true positives as possible, they have a very high predictive

                                                                                                               11
value, especially when used in high-risk populations, where the number of diseased people is high. The
predictive value of positive test results generally decreases when performed in low-risk populations, where
there are fewer diseased persons.

Prevalence - The number of people in a given population who have a disease, divided by all the people in
that population over a specific point in time. (e.g. the proportion of the population with disease).

Protease - An enzyme made by HIV that modifies HIV proteins and is necessary for the virus to reproduce.

Protease Inhibitor - A class of drugs that prevents the HIV protease enzyme from working by binding to
the active site in the enzyme where the HIV amino acid chain would lie to be cut or cleaved into its active
parts or proteins. The commonly used medications include: indinavir (Crixivan), atazanavir, ritonavir
(Norvir), saquinavir (Fortase and Invirase), nelfinavir (Viracept), amprenavir (Agenerase). Drug levels in
the patients bloodstream can be increased by blocking the metabolism (degradation or breakdown) of the
medication in the liver using low doses of ritonavir. This is called protease inhibitor boosting. One drug
Kaletra has combined lopinavir, a protease inhibitor with a small amount of ritonavir in the same capsule.

Retrovirus - A special group of viruses that are proven to cause a variety of diseases in animals. A special
type of retrovirus, the Human Immunodeficiency Virus (HIV), is believed to be the virus which causes
AIDS.

Reverse Transcriptase - The enzyme unique to retroviruses that allows them to copy RNA to DNA and
replicate themselves in the genetic material of the cell.

Risk Factors - Any personal characteristic or behavior that increases the likelihood that a person will be
affected by a given condition. The risk factors that are believed to increase the chances of transmitting HIV
infection include engaging in intimate sexual contact (in particular, vaginal or anal intercourse) without a
condom, sharing IV needles, and other activities which involve the exchange of infected body fluids. Co-
factors are additional characteristics or other conditions that work with other risk factors to increase the
chances of getting a disease. For instance, having a diagnosed sexually transmissible disease or already
weakened immune system are believed to be co-factors or increase the chances of being infected with HIV
or progressing to AIDS.

Screening - The process of identifying undetected infection or disease by using test, examinations or other
procedures. These are usually simple, quick procedures that can be applied to large numbers of people.
The tests are used to separate apparently well individuals who probably have a disease from those who
probably do not. A screening test is not designed to diagnose a disease. It is important for persons testing
positive on a screening procedure to be diagnosed and receive appropriate treatment, if necessary.
Generally, screening tests are directed towards or used in populations considered to be at higher risk of
contracting a disease.

Sensitivity - The ability of a screening test to identify correctly individuals with a disease or condition --
i.e., to identify "true positives". Most HIV antibody tests are highly sensitive, with the sensitivity of
currently licensed tests averaging 99% or greater under optimal laboratory conditions. However, the
sensitivity of the tests, or their ability to identify true positives, may vary according to the manufacturer of
the test kit used, the prevalence of HIV infection in the test population, the quality assurance standards
employed by the testing laboratory, the interpretation of the test results and the standardization of values to
determine the presence of HIV antibodies.

Seroconvert - The appearance of antibodies to HIV in the blood made by an individual’s immune system
in response to exposure and infection by the virus. The change is described as: from seronegative to
seropositive. Because it may take from three weeks to two months for HIV antibodies to appear, (window
of seroconversion) , it may be necessary to retest high-risk patients after this period of time, who originally
test negative.


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Seronegative - The status of a person's blood when it is tested and the results cannot confirm that HIV
antibodies are present. Generally, a person is considered to be seronegative if: 1) the initial ELISA is
negative; 2) the initial ELISA is positive and the repeat ELISA in negative; or 3) both ELISA's are positive
and the Western Blot is negative.

Seropositive - The status of a person's blood when it is tested and the results reveal HIV antibodies - as
generally determined by two positive ELISA's and a positive Western Blot.

Shingles - A blistering skin rash caused by reactivation of the dormant chicken pox virus, varicella zoster.

Seroprevalence - The relative frequency or number of individuals in a given population or community
whose blood tests positive for an infection, in this case for HIV infection.

Significant Exposure to HIV Infection - A person is believed to be at particularly high risk of contacting
HIV infection if he or she:

     is or was a sexual partner of an HIV-infected person;
     has shared needles with an HIV-infected drug user;
     was injected with or has broken or abraded skin exposed to substantial amounts of blood or body
      fluid from HIV-infected individuals;
     has received blood, semen or body organs donated by an HIV-infected patient;
     is a child born to an HIV-infected mother.

Vaginal intercourse allows for male-to female transmission, but less frequently than via anal intercourse.
Female-to-male transmission via vaginal intercourse is believed to be a less-frequent means of transmitting
the infection. Persons, who have contacts with HIV-infected individuals via other means, such as through
sharing residential or workplace facilities, or casual kissing, are not at high risk of being infected.
Therefore, these persons are not considered to have had significant exposure to HIV infection.

Specificity - the ability of a screening test to identify correctly people who do not have a specific disease or
condition. To increase the chances that true negatives are identified using HIV antibody tests, a series of
tests are usually given and an individual must test positive on all three tests to be found positive. The
specificity of currently licensed ELISA tests is 99% if repeat tests are completed.

Surveillance - Surveillance of disease involves collecting, analyzing and interpreting public health data.
This is done systematically and on an on-going basis to study how disease occurs and spreads through the
population. The data may also be used to help design programs to help prevent and control the spread of
disease.

Thrush - A mouth infection caused by a yeast, candida.

T-Lymphocyte (T-Cell) - A type of white blood cell that is essential to the body's immune system in its
fight against infection. T-cells help regulate the production of substances called antibodies. T4
lymphocytes are a special subset of T-cells. T4 or CD4 cells start the body's immune response and help the
body protect itself against viruses, parasites, tumors and fungi. The HIV virus interferes with the function
of the T4 cells.

Transmission - The way in which a disease can be transferred from one person to another or the way in
which a person is exposed to the disease. HIV may be transmitted in three main ways:
    Through intimate, unprotected sexual contact: male to male and anal sexual intercourse are
        believed to be the most efficient means of transmitting HIV. Male-to-female transmission occurs,
        but less frequently. Female-to-male sexual contact is currently believed to be a less frequent means
        of transmitting the infection.
    Through parenteral exposure: through injections with contaminated or unsterilized needles. This
        primarily occurs with drug users who share needles when injecting drugs. Injection with contaminated

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      blood products, through blood transfusions received before 1985, was also a route of transmission. In
      resource poor countries, reuse of needles in the health care setting and transfusion of blood products
      which have not been screened for HIV is also a means of transmission.
     Through perinatal transmission: transfer of HIV from the mother to the infant, either (a) through
      the placenta before the infant is born; (b) during the birth process itself; or (c) soon after birth
      through breast milk. Studies are still being conducted to see which mode of transmission occurs
      most frequently. Such information will help physicians decide the best way to care for pregnant
      women, new mothers and their infants who may be at risk of HIV infection. It is currently
      estimated that there is up to a 33 percent chance that an infected untreated mother will pass the
      virus to her child. The risk of transmission is higher when the mother has a higher viral load, a
      lower CD4 count. Transmission through breastmilk is higher if the mother has mastitis.

True Negative - When test results from a healthy (i.e., non-diseased) individual fail to show the presence
of a disease or condition. Commonly, to be considered a “true negative” for HIV infection, a person tests
negative on one of two ELISA's or tests negative on the confirmatory Western Blot test.

True Positive - When test results from a diseased individual show the presence of the disease or condition.
Commonly, to be considered a “true positive” for HIV infection, a person with HIV antibodies must have
two positive ELISA tests confirmed by a positive Western Blot test.

Universal Precautions - This is the policy currently in practice in the U.S. for prevention of spread of HIV
from patients to health care workers. It assumes that anyone can be infected with HIV or other blood born
pathogens and thus health care workers should maintain the same precautions with all patients regardless of
their HIV status.

Vaccine - A drug made from non-living or modified virus, bacteria, etc., primarily to prevent certain
infectious diseases. Vaccines stimulate the body's defense mechanisms, helping it to develop an immunity
to the disease without actually causing the disease itself.

Viral Load - A direct measurement of the amount of HIV in blood or genital secretions using viral genetic
amplification techniques such as PCR (Polymerase Chain Reaction).

Virus - A tiny, submicroscopic microorganism only capable of growth and multiplication in living cells
that causes infectious diseases.

Western blot - This is a highly sensitive blood test that is able to identify and measure most, if not all, of
the HIV antibodies in a blood sample. This more expensive test uses viral proteins separated by size that
attach to the HIV antibodies in the patient's serum. It is used to confirm previously positive ELISA's; when
patients test positive on the Western Blot, it is assumed that they have HIV antibodies.




                                                                                                           14
                             DEFINITIONS OF AIDS-RELATED DISEASES

The following diseases are those that are used formally by the Centers for Disease Control (CDC) of the
Public Health Service to diagnose persons with AIDS. The benchmark diseases and conditions are being
reviewed by CDC on an ongoing basis as more is learned about the disease. AIDS dementia and chronic
wasting syndrome have been added to the AIDS case definition, as well as Mycobacterium Tuberculosis
(TB), and anyone who is HIV positive and has a CD4 count less than 200.

A.      Infections

      Protozoan Infections

      Pneumocystis carinii pneumonia (PCP) - The most common opportunistic infection in patients with
      AIDS. Over 61 percent of untreated AIDS patients are initially diagnosed with PCP. This type of
      pneumonia or lung infection is caused by a protozoa which is commonly present in the
      environment but which is normally suppressed in people who have healthy immune systems. A
      person who develops PCP is likely to get the disease again and the outcome is often fatal. This
      usually occurs in patients with a CD4 count less than 200.

      Toxoplasma gondii encephalitis - An infection in the brain leading to several
      different types of neurologic disorders. This usually occurs in patients with a CD4 count less than
      100.

      Cryptosporidium enteritis - Caused by a protozoan parasite that usually lodges in the intestines and
      causes chronic severe diarrhea for more than one month. While the infection seems to be occurring
      more frequently in immune-suppressed people, the condition also appears in healthy persons but is
      usually self-limited.

      Isospora enteritis - Another acute form of diarrhea for more than one month caused by a coccidium
      parasite that occurs rarely in healthy adults.

      Fungal Infections

      Cryptococcal meningitis - An infection of the membranes surrounding the brain
      and the spinal cord, caused by a fungus Cryptococcus neoformans. This type of meningitis with
      headache, blurring vision, confusion, depression, agitation or inappropriate speech may be fatal.
      This usually occurs in patients with a CD4 count less than 200.

      Oral and esophageal candidiasis - A yeast infection of the mouth and esophagus,
      common in AIDS patients, characterized by white patches, reddened mucous membranes and some
      discomfort in chewing and swallowing.

      Disseminated histoplasmosis - A rare disease mainly caused by inhaling spores
      from soil contaminated by bats, chickens, starlings, or other animals that carry histoplasma species.
      The histoplasma fungus causes lesions in the liver, spleen, lymph nodes, lining of the brain and
      spinal cord, adrenal glands and bone marrow.




                                                                                                          15
     Bacterial/Viral Infections

     Disseminated mycobacterium avium - (MAI or MAC) This bacterial infection, causing chronic
     acute lung diseases, was uncommon in humans before AIDS. It is caused by a different species of
     the same bacteria that causes tuberculosis. This usually occurs in patients with CD4 count less than
     100 and infects the blood stream causing high fevers, diarrhea and painful swollen lymph nodes.

     Mycobacterium Tuberculosis - the causal agent of classic TB which can also infect any organ
     system.

     Chronic mycocutaneous herpes simplex - An ulcerative disease of the mucus membranes (e.g.
     mouth, anus, vagina) caused by a herpes virus.

     Cytomegalovirus (CMV) infection of organs other than lymph nodes and liver - An infection by a
     virus related to the herpes family that produce mild flu-like symptoms, including aching, fever,
     mild sore throat, weakness and enlarged lymph nodes. In persons whose immune systems are
     impaired, the symptoms may be far more severe, resulting in hepatitis, mononucleosis, pneumonia
     or retinitis (eye). This occurs in patients with a CD4 count less than 50.

B.    Cancers

     Kaposi's Sarcoma (KS) - Before the advent of the HIV/AIDS epidemic, KS was a cancer found
     rarely in persons under 60 years of age. It is caused by a herpes virus, KSHV. With KS, tumors
     usually appear in the walls of the blood vessels, causing painless purple spots to appear on the skin.
     The tumors may also grow on the internal organs and death usually occurs when the major organs
     become involved. Persons over 60 years of age with KS who test positive for HIV could also have
     AIDS.

     Primary brain lymphoma- A malignant tumor of the lymphoid tissue on the brain.

     Diffuse, Undifferentiated, Non-Hodgkin's Lymphomas (DUNHL) - A malignant tumor of the
     lymphoid tissue of the central nervous system. DUNHL patients exhibit swollen, firm and possibly
     tender lymph glands and enlarged spleens. This type of cancer is usually fatal.

     (AIDS Course 2008 syllabus FINAL.doc) 10-24-07




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