Disusun oleh :

Dr. H. Deddy Hartanto

 Etiologivirus dari Acquired
Immunodeficiency Syndrome (AIDS).
ADA 2 jenis virus HIV : HIV-1 dan HIV-2
HIV -1ditemukan oleh Luc Montagnier of
France dan Robert Gallo dari USA in 1983-84.
Nama-nama lain dari virus HIV:
Human T cell lymphotrophic virus (HTLV-III)
Lymphadenopathy associated virus (LAV)
AIDS associated retrovirus (ARV)
 HIV -1 menyebar lebih banyak daripada HIV-
2 di seluruh dunia.
HIV-2 ditemukan th 1986, antigen virus
menyebar scr endemis di Afrika barat.
1 juta orang terinfeksi di USA, menyebar 30
juta orang seluruh dunia terinfeksi (2005).
Penyebab kematian utama pada laki2 umur
25-44 th dan penyebab ke 4 kematian wanita
di USA.
 Icosahedral (20 sisi), enveloped virus,
subfamili lentivirus dari retroviruses.
Retroviruses menyalin RNA ke DNA.
2 helai virus dari RNA ditemukan dalam
inti yg dikelilingi oleh pelapis luar
protein.
Outer envelope contains a lipid matrix within
which specific viral glycoproteins are
imbedded.
These knob-like structures responsible for
binding to target cell.
 The outer shell of the virus is
known as the Viral enevlope.
Embedded in the viral
envelope is a complex protein
known as env which consists
of an outer protruding cap
glycoprotein (gp) 120, and a
stem gp14. Within the viral
envelope is an HIV protein
called p17(matrix), and
within this is the viral core or
capsid, which is made of
another viral protein
p24(core antigen).
 Three main structural genes:
Group Specific Antigen (Gag)
Envelope (Env)
Polymerase (Pol)
 Located in nucelocapsid of virus.
Icosahedryl capsid surrounds the internal
nucleic acids made up of p24 andp15.
p17 lies between protein core and envelope
and is embedded in the internal portion of
the envelope.
Two additional p55 products, p7 and p9, are
nucleic acid binding proteins closely
associated with the RNA.
 Envelope (Env) gene codes for envelope
proteins gp160, gp120 and gp41.
These polyproteins will eventually be cleaved
by proteases to become HIV envelope
glycoproteins gp120 and gp41.
gp160 cleaved to form gp120 and gp41.
gp120 forms the 72 knobs which protrude from
outer envelope.
gp41 is a transmembrane glycoprotein antigen
that spans the inner and outer membranes and
attaches to gp120.
gp120 and gp41 both involved with fusion and
attachment of HIV to CD4 antigen on host
cells.
 Polymerase (Pol) codes for p66 and p51
subunits of reverse transcriptase and p31 an
endonuclease.
Located in the core, close to nucleic acids.
Responsible for conversion of viral RNA into DNA,
integration of DNA into host cell DNA and
cleavage of protein precursors.
 First
step, HIV attaches to susceptible
host cell.
Site of attachment is the CD4 antigen found on
a variety of cells
helper T cells
macrophages
monocytes
B cells
microglial brain cells
intestinal cells
T cells infected later on.
 Inearly phase HIV
infection, initial
viruses are M-tropic.
Their envelope
glycoprotein gp120 is
able to bind to CD4
molecules and
chemokine receptors
called CCR5 found on
macrophages
 Inlate phase HIV
infection, most of the
viruses are T-tropic,
having gp120 capable
of binding to CD4 and
CXCR4 found on T4-
lymphocytes.
 (a) HIV (red) attaches to two cell-surface receptors
(the CD4 antigen and a specific chemokine
receptor).
(b) The virus and cell membrane fuse, and the
virion core enters the cell.
(c) The viral RNA and core proteins are released
from the virion core and are then actively
transported to the nucleus.
(d) The viral RNA genome is converted into double-
stranded DNA through an enzyme unique to viruses,
reverse transcriptase (red dot).
(e) The double-stranded viral DNA moves into the
cell nucleus.
(f) Using a unique viral enzyme called integrase, the
viral DNA is integrated into the cellular DNA.
(g) Viral RNA is synthesized by the cellular enzyme
RNA polymerase II using integrated viral DNA as a
template. Two types of RNA transcripts shorter
spliced RNA (h) and full-length genomic RNA (j) are
produced.
(h) Shorter spliced RNAs are transported to the
cytoplasm and used for the production of several
viral proteins that are then modified in the Golgi
apparatus of the cell (i).
(j) Full-length genomic RNAs are transported to the
cytoplasm (k).
(l) New virion is assembled and then buds off.
(m) Mature virus is released.
 The gp120 protein on virus binds specifically
to CD4 receptor on host cell with high
affinity.
Gp41 causes fusion of the virus to the cell
membrane.
After fusion virus particle enters cell.
Viral genome exposed by uncoating particle.
 Reverse
transcriptase produces viral DNA
from RNA.
Becomes a provirus which integrates into host
DNA.
Period of latency occurs.
 After a period of latency lasting up to 10
years viral replication is triggered and
occurs at high rate.
CD4 cell may be destroyed in the process,
body attempts to replace lost CD4 cells,
but over the course of many years body is
unable to keep the count at a safe level.
Destruction of large numbers of CD4
cause symptoms of HIV to appear with
increased susceptibility to opportunistic
infections, disease and malignancy.
 Transmisi Penularan :
Sexual transmission, presence of STD increases
likelihood of transmission.
Exposure to infected blood or blood products.
Use of contaminated clotting factors by
hemophiliacs.
Sharing contaminated needles (IV drug users).
Transplantation of infected tissues or organs.
Mother to fetus, perinatal transmission
variable, dependent on viral load and mothers
CD 4 count.
 sptinfeksi Mononucleosis-like, gejala spt
batuk pilek dapat timbul 6 -12 weeks
setelah infeksi :
lymphadenopathy
Demam
Rash ( bercak kemerahan di tubuh )
Pusing
Lelah
DIare
Sakit tenggorokam
Manifestasi gangguan syaraf
Kadang2 tanpa gejala yg jelas.
 Gejala relatif tidak spesifik.
Test Anti HIV sering negatif tetapi bisa
menjadi positif 3- 6 bulan kemudian,
proses ini dinamakan serokonversi.
Jumlah yang besar dari HIV banyak
didapatkan di darah perifer.
HIV pada fase primer ini dapat didiagnosa
menggunakan pemeriksaan virus load
titer atau test yang lain.
Orang yang terinfeksi HIV pada fase
primer bisa tanpa gejala selama waktu
yang lama, sering bertahun-tahun.
 HIV berkelanjutan berproduksi, jumlah
CD4 secara bertahap menurun dari jumlah
normalnya yaitu 500-1200.
Sewaktu CD4 jumlahnya menurun dari
500, orang yg terinfeksi HIV mempunyai
resiko terkena infeksi2 opportunistik dari
luar.
Berikut ini adalah penyakit2 yang
diprediksi mengarah progresivitas kearah
AIDS:
persistent herpes-zoster infection (shingles)
oral candidiasis (thrush)
oral hairy leukoplakia
Kaposis sarcoma (KS)
 Being that HIV reduces immunologic activity, the
intraoral environment is a prime target for chronic
secondary infections and inflammatory processes,
including OHL, which is due to the Epstein-Barr virus
under immunosuppressed conditions
 Kaposis sarcoma (shown)
is a rare cancer of the
blood vessels that is
associated with HIV. It
manifests as bluish-red
oval-shaped patches that
may eventually become
thickened. Lesions may
appear singly or in
clusters.
 Dihitung CD4 menurun <200 maka orang ini
dipertimbangkan mendapatkan penyakit HIV yg
tahap lanjut kearah AIDS.
Bila pencegahan secara medis tidak dimulai
maka infeksi HIV mempunyai resiko untuk:
Pneumocystis carinii pneumonia (PCP)
cryptococcal meningitis
toxoplasmosis
Bila dihitung CD4 < 50:
Mycobacterium avium
Cytomegalovirus infections
lymphoma
dementia
Banyak terjadi kematian padaCD4 < 50.
 Respiratory system
Pneumocystis Carinii Pneumonia (PCP)
Tuberculosis (TB)
Kaposi's Sarcoma (KS)
Gastro-intestinal system
Cryptosporidiosis
Candida
Cytomegolavirus (CMV)
Isosporiasis
Kaposi's Sarcoma
Central/peripheral Nervous system
Cytomegolavirus
Toxoplasmosis
Cryptococcosis
Non Hodgkin's lymphoma
Varicella Zoster
Herpes simplex
Skin
Herpes simplex
Kaposi's sarcoma
Varicella Zoster
 Gangguan perkembangan
Jamur mulut yg persistent
Hepato megali
Pembesaran KGB
Diare berulang
Infeksi bakteri berulang
ditemukan gangg.syaraf.
 Earlystage slight depression of CD4 count,
few symptoms, temporary.
Window of up to 6 weeks before antibody is
detected, by 6 months 95% positive.
During window p24 antigen present, acute
viremia and antigenemia.
 Antibodies produced to all major antigens.
First antibodies detected produced against gag
proteins p24 and p55.
Followed by antibody to p51, p120 and gp41
As disease progresses antibody levels decrease.
 Immune abnormalities associated with
increased viral replication.
Decrease in CD4 cells due to virus budding
from cells, fusion of uninfected cells with
virally infected cells and apoptosis.
B cells have decreased response to antigens
possibly due to blockage of T cell/B cell
interaction by binding of viral proteins to CD4
site.
CD8 cells initially increase and may remain
elevated.
As HIV infection progresses, CD4 T cells drop
resulting in immunosuppression and
susceptibility of patient to opportunistic
infections.
Death comes due to immuno-incompetence.
 Target cell adalah T.helper (CD4+)
Normal :CD4+ : 65 % dan CD8+ : 35% dari total T-
cell
Pada penderita AIDS konsentrasi CD4+ menurun
secara
drastis.
Konsentrasi CD4+ dihubungkan dengan
konsentrasi CD8 .
Menyebabkan rasio CD4+ / CD8 terbalik pada HIV
/ AIDS
The Move Toward Lower Pill Burdens
Regimen Dosing Daily pill burden

1996
Zerit/Epivir/Crixivan 10 pills, Q8H

1998
Retrovir/Epivir/Sustiva 5 pills, BID

2002
Combivir (AZT/3TC)/EFV 3 pills, BID

2003
Viread/ Emtriva/Sustiva 3 pills, QD
2004
Truvada/Sustiva 2 pills, QD
 symptoms symptoms
HIV proviral DNA

HIV antibodies
window
period

HIV viral load

HIV-1 p24 antigen

0 1 2 3 4 5 6 / 2 4 6 8 10
1 infection weeks years
Time following infection
 Menggunakan metode yg mendeteksi:
Antibody
Antigen
Viral nucleic acid
Kultur Virus
TENTANG STANDAR PELAYANAN LABORATORIUM KESEHATAN
PEMERIKSA HIV DAN INFEKSI OPORTUNISTIK
Tentang Penggunaan strategi III :
Kombinasi 3 reagen rapid test HIV Tujuan Diagnosis.
Strategi III dengan persyaratan reagensia sebagai berikut :
1. Sensitivitas reagen pertama >99%
2. Spesifisitas reagen kedua > 98%
3. Spesifitas reagen ketiga > 95%
Untuk tujuan surveilans :
reagen pertama harus memiliki sensitiviras >99%. Spesifisitas
reagen kedua >98%. Semua regensia yang dipakai harus terdaftar
di DepKes RI
 Pemeriksaan anti-HIV disertai informed
consent tertulis,
sebelumnya didahului dengan konseling pra-
uji / test dan
sesudahnya konseling pasca-uji / test
Pelaporan pemeriksaan
dilaporkan reaktif dan non reaktif.
KERAHASIAAN!!!!
 test
serologi awal yg dikembangkan untuk
mendeteksi Infeksi HIV :
Mudah digunakan.
Mudah adaptasi utk test batch.
Sensitivitas dan spesifisitasnya tinggi.
Antibodi2dideteksi oleh ELISA termasuk yang
melawan antigen : p24, gp120, gp160 and
gp41, Terdeteksi utk infeksi awal dan muncul
pada semua orang yg terinfeksi.
 ELISA test digunakan utk:
Screening product2 darah.
Diagnosis dan monitoring patients.
Menentukan prevalensi dari infeksi
Penelitian.
 Ada 3 teknik metode yang digunakan:
indirect
competitive
sandwich
ELISAshanya utk penyaring saja,, positives
palsu dapat timbul dan mungkin bisa terjadi
pada AI disease, alcoholism, syphilis, and
immunoproliferative diseases.
 Agglutination tests using latex particles,
gelatin particles or microbeads are coated
with HIV antigen and will agglutinate in
the presence of antibody.
Dot-Blot Testing utilizes paper or
nitrocellulose impregnated with antigen,
patient serum is filtered through, and
anti-antibody is added with enzyme label,
color change is positive.
A rapid, cost-effective and may become an
alternative to standard ELISA and Western blot
testing.
 Test Konfirmasi yang paling populer :
Memanfaatkan preparasi lysate dari HIV virus.
lysate adalah electrophoresis yang digunakan
utk memisahkan keluar dari protein HIV
(antigens).
Kertas dipotong kedalam strips dan direaksikan
dengan sera test.
Setelah inkubasi dan pencucian anti antibodi
dengan ditambah radioisotop atau enzym.
Pita2 spesifik dimana antibodi direaksikan
dengan antigen2 yang berbeda.
Reagen yang terbanyak dari test ini adalah
yang paling murni kualitas antigen HIV nya.
Antigen2 yang harus ada dalam pemeriksaan
sbb: p17, p24, p31, gp41, p51, p55, p66,
gp120 and gp160.
 Antibodi terhadap p24 dan p55 muncul lebih
awal tetapi jumlah menurun dan menjadi
tidak ditemukan.
Antibodi terhadap gp31, gp41, gp 120, and
gp160 muncul belakangan tetapi selalu ada
pada setiap tingkat dari penyakit.
 gp160
gp120

p68
p55
p53
gp41-45

Spectrum p40
p34
of anti-HIV p24

testing p18

p12

early recent / established advanced

DNA PCR
RNA PCR
p24 Ag
3rd gen ELISA
1st gen ELISA
Detuned ELISA
1wk 2wk 3wk 2mo 6mo 1yr 2yr 3yr +8yr
 Hasil interpretasi :.
Tidak ditemukan di pita2 (bands), negative.
Supaya hasil dikatakan positif bila ada 3 bands
yang melawan antigen yang harus didapatkan
yaitu : p24, p31, gp41 atau gp120/160.
CDCcriteria memerlukan 2 bands dari: p24,
gp41 or gp120/160.
 Mahal : $ 80 - 100
Teknik Lebih Sulit
Interpretasi scr visual
Gold Standard untuk
Konfirmasi
 Indeterminate results are those samples that
produce bands but not enough to be positive,
may be due to the following:
prior blood transfusions, even with non-HIV-1 infected
blood
prior or current infection with syphilis
prior or current infection with malaria
autoimmune diseases (e.g., diabetes, Graves disease,
etc)
infection with other human retroviruses
second or subsequent pregnancies in women.
run an alternate HIV confirmatory assay.
Quality control of Western Blot is critical and
requires testing with strongly positive, weakly
positive and negative controls.
 Dapat digunakan utk mendeteksi virus
maupun antibodinya.
Antibody dideteksi dengan test serum pasien
melawan antigen yang dipaparkan pada slide,
diinkubasi, dicuci dan ditambah flourescent
antibodi.
Virus dideteksi oleh sel pasien yang difiksasi
dan diinkubasi dengan antibodi.
 Pemeriksaan p24-antigen adalah metode
EIA yg menggunakan bahan serum atau
plasma.
P24 antigen hanya muncul pada waktu yg
singkat, menghilang ketika terbentuk
antibodi terhadap p24 muncul.
Anti-HIV-1 bound to membrane, incubated
with patient serum, second anti-HIV-1
antibody attached to enzyme label is
added (sandwich technique), color change
occurs.
Optical density measured, standard curve
prepared to quantitate results.
 Positive confirmed by neutralizing reaction,
preincubate patient sample with anti- HIV,
retest, if p24 present immune complexes
form preventing binding to HIV antibody on
membrane when added.
Test tidak direkomendasi utk screening rutin
sebab munculnya tidak bisa ditebak.
Sensitivitas lebih rendah dari ELISA.
 Paling banyak digunakan utk::
Infeksi awal yang diduga pasien yg hasilnya
secara serologi negatif .
Anak baru lahir
deteksi cairan serebro spinalis
monitoring progres penyakit
 Looks for HIV DNA in the WBCs of a person.
PCR amplifies tiny quantities of the HIV DNA
present, each cycle of PCR results in doubling of
the DNA sequences present.
The DNA is detected by using radioactive or
biotinylated probes.
Once DNA is amplified it is placed on
nitrocellulose paper and allowed to react with a
radiolabeled probe, a single stranded DNA
fragment unique to HIV, which will hybridize
with the patients HIV DNA if present.
Radioactivity is determined.
 Virus isolation dapat digunakan sebagai
diagnosa HIV scr definitif.
Bahan terbaik adalah darah perifer tapi
bisa menggunakan cairan sumsum, air liur,
sekret cervik, semen dan airmata atau
jaringan dari organ biopsi.
Pertumbuhan sel yg dibiakkan dirangsang
dan jumlahnya dilipatgandakan utk
menghasilkan virus.
Kultur diinkubasi selama 1 bulan,
konfirmasi infeksi terdeteksi p24 antigen
yg berada di supernatan.
 Viral load atau viral burden adalah jumlah
dari HIV-RNA yang berada dalam darah
dengan menggunakan metode PCR.
RNA adalah material genetik dari HIV yang
berisi informasi utk membuat lebih banyak
virus.
 Viralload tests diukur jumlah dari HIV
dalam satu mililiter darah.
Perlu dua kali pengukuran dengan jarak 2-
3 minggu utk menentukan jumlah
rata2nya.
Diulang setiap 3-6 bulan dihubungkan
dengan jumlah CD 4 utk memonitor viral
load dan jumlah T-cell.
Diulang 4-6 minggu setelah memulai atau
merubah obat anti retroviral utk
menentukan efeknya terhadap viral load.
 Difficultdue to presence of maternal IgG
antibodies.
Use tests to detect IgM or IgA antibodies, IgM
lacks sensitivity, IgA more promising.
Measurement of p24 antigen.
PCR testing may be helpful but still not
detecting antigen soon enough: 38 days to 6
months to be positive.
 http://www.cat.cc.md.us/courses/bio141/lecguide/unit2/viruses/hivlc.h
tml#translat

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aids.edu/publications/pocketguide/pocketgd0105.pdf
http://www.modares.ac.ir/sci/saman_h/Pages/application
s.htm
http://hivinsite.ucsf.edu/InSite?page=kb-02&doc=kb-02-
02-02-02
http://www.hivandhepatitis.com/recent/test/realtime/06
1604_f.html