HIV- AIDS BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE CHINKI PORA SOPORE KASHMIR EMAIL—drbashir123@gmail.com

AIDS is caused by human immunodeficiency virus Genetically the virus has two types HIV-1 (World wide) HIV-2 which is less aggressive slow and restricted mainly to western Africa.

How it got transferred to humans The HIV-1 actually got transfered from African green monkeys or chimpanzees

How it got transferred to humans HIV-2 got transferred from Sooty managbey monkeys or Chimpanzees

Natural transfer theory Commonly held theory is that HIV got transferred through hunting and handling of chimpanzees and through slaughtering and eating “bush meat” of these (monkeys).The epidemic required urbanization and increased population mobility

Human error theory Oral polio vaccine or some other injectable vaccines used enmass in West Africa during the late 1950s may have been contaminated with HIV since these vaccines were prepared by using these monkeys or their tissues in process of their preparation.

How HIV can be transmitted Unprotected sexual contact – be it vaginal, oral, or anal Mucosa - with an infected partner Contact of abraded skin or mucosa with body secretions such as blood, CSF or semen;

Actually making sex with Bugs

How HIV can be transmitted Sharing unsterilized needles or syringes with an HIV positive person, for example, when using drugs or in a healthcare setting. During pregnancy or birth and through breastfeeding from an HIV positive mother to her baby. Blood transfusions with infected blood Accidental occupational exposure

Populations particularly at risk Has a sexually transmitted infections(STIs) Has anal sex with her/his partner(s) Exchanges sex for money or drugs Has many sex partners Non-circumcised

Populations particularly at risk Leads life separated from spouse due to professional obligations (e.g., truck drivers, laborers, migrants) Homosexuals/ bisexuals Certain sexual practices increases the disease Like sexual Contact with Male-to-male Female-to-female

How HIV can NOT be transmitted Through air or by coughing and sneezing Through food or water Through sweat and tears

How HIV can NOT be transmitted By sharing cups, plates, and utensils with an infected person By touching, hugging and kissing an infected person By sharing clothes or shaking hands with an infected person By sharing toilets and bathrooms with an infected person By living with an infected person By mosquitoes, fleas, or other insects

How HIV can NOT be transmitted While the virus has occasionally been found in saliva, tears, urine and bronchial secretions, transmission after contact with these secretions has not been reported. No laboratory or epidemiological evidence suggests that biting insects have transmitted HIV infection.

26 CONCENTRATION OF VIRUS Blood, Menstrual Blood – Very High Vaginal Fluids, Semen, Pre ejaculate Fluid – High Bone Marrow – High Saliva – No Sweat, Tears, urine - No

HIV in Body Fluids Semen 11,000 Vaginal Fluid 7,000 Blood 18,000 Amniotic Fluid 4,000 Saliva 1 Average number of HIV particles in 1 ml of these body fluids

HIV STRUCTURE HIV belongs to a special class of viruses called retroviruses. Within this class, HIV is placed in the subgroup of lentiviruses. Other lentiviruses include SIV, FIV, Visna and CAEV, which cause diseases in monkeys, cats, sheep and goats. All viruses except retroviruses contain DNA

HIV STRUCTURE So Retroviruses are the exception because their genes are composed of RNA (Ribonucleic Acid). However RNA has a very similar structure to DNA with small differences

HIV STRUCTURE HIV has just nine genes (compared to more than 500 genes in a bacterium Three of the HIV genes, called gag, pol and env, contain information needed to make structural proteins for new virus particles.

HIV STRUCTURE The other six genes, known as tat, rev, nef, vif, vpr and vpu, code for proteins that control the ability of HIV to infect a cell, produce new copies of virus, or cause disease.

HIV STRUCTURE An HIV particle is around 100-150 billionths of a metre in diameter. That's about the same as: 0.1 microns 4 millionths of an inch one twentieth of the length of an E. coli bacterium one seventieth of the diameter of a human CD4+ white blood cell.

HIV STRUCTURE HIV particles surround themselves with a coat of fatty material known as the viral envelope . This envelope gives out lots of little spikes around 72 in number.

HIV STRUCTURE These spikes are made of knobs and handles made of proteins gp120 and gp41 respectively.

HIV STRUCTURE Just below the viral envelope is a layer called the matrix, which is made from the protein p17(Matrix proteins)

HIV STRUCTURE Below the matrix is another layer of proteins P24 forming viral core (or capsid) and is usually bullet-shaped.

HIV STRUCTURE Inside the core are three enzymes required for HIV replication called Reverse transcriptase Integrase And protease

HIV STRUCTURE Also held within the core is HIV's genetic material, which consists of two identical copies of single stranded RNA.

The virus, entering through which ever route, acts primarily on the following cells: * Lymphoreticular system: o CD4+ T-Helper cells o CD4+ Macrophages o CD4+ Monocytes o B-lymphocytes *

The virus, entering through which ever route, acts primarily on the following cells: Certain endothelial cells * Central nervous system: o Microglia of the nervous system o Astrocytes o Oligodendrocytes o Neurones - indirectly by the action of cytokines and the gp-120

Pathogenesis HIV binds to CD4 molecule, CD4 molecule is found on the T helper-cell Macrophages etc.Binding of CD4 is not sufficient for entry Therefore gp120 protein also binds to co-receptor CCR5 Co-receptor - is used by macrophages CXCR4 Co-receptor - is used by lymphocytes

Pathogenesis Binding of virus to cell surface results in fusion of viral envelope with cell membrane of T-helper cell and thus Viral core is released into cell cytoplasm After uniting with T-helper cells the T-Helper cells through Th1 - activate Tc (CD8) lymphocytes, promoting cell-mediated immunity Th2 - activate B lymphocytes, promoting antibody mediated immunity

Pathogenesis CD8 Cytotoxic T lymphocyte (CTL) is Critical for containment of HIV.Derived from T8 cells, recognize viral antigens and directly destroy infected cells

Pathogenesis Antibodies formed bind to surface of virus to prevent attachment to target cells Fc portion of antibody also binds to NK cells and Stimulates NK cell to destroy infected cell

Pathogenesis Numerous organ systems are infected by HIV: Brain: macrophages and glial cells Lymph nodes and thymus: lymphocytes and dendritic cells Blood, semen, vaginal fluids: macrophages Bone marrow: lymphocytes Skin: langerhans cells Colon, duodenum, rectum: chromaffin cells Lung: alveolar macrophages

Pathogenesis About (10 billion) virions are produced daily Average life-span of an HIV virion in plasma is ~6 hours Average life-span of an HIV-infected CD4 lymphocytes is ~1.6 days HIV hides in cells like CNS etc and can lie dormant within a cell for many years, especially in resting (memory) CD4 cells, unlike other retroviruses etc

Pathogenesis All elements of immune system are affected. Advanced stages of HIV are associated with destruction and disruption of lymphoid tissue(T-helper cells etc) that result in Impaired ability to mount immune response Impaired ability to maintain memory responses Loss of containment of HIV replication ultimately results in severe immunosuppression susceptibility to opportunistic infections

HIV Life Cycle Step 1: Attachment of virus at the CD4 receptor and chemokine co-receptors CXCR4 or CCR5

HIV Life Cycle Step 2: viral fusion and uncoating

HIV Life Cycle Steps 3-5: Reverse transcriptase makes a single DNA copy of the viral RNA and then makes another to form a double stranded viral DNA

HIV Life Cycle Step 6: migration to nucleus

HIV Life Cycle Steps 7-8: Integration of the viral DNA into cellular DNA by the enzyme integrase

HIV Life Cycle Steps 9-11: Transcription and RNA processing

HIV Life Cycle Steps 12-13: Protein synthesis

HIV Life Cycle Step 14: protease cleaves polypeptides into functional HIV proteins and the virion assembles Step 15: virion budding Step 16: Virion maturation

HIV Life Cycle

Window period The window period begins at the time of infection and can last 4 to 8 weeks. During this period, a person is infected, infectious and viremic, with a high viral load and a negative HIV antibody test. The point when the HIV antibody test becomes positive is called the point of seroconversion.

Window Period Some times 90 percent of cases test positive within three months of exposure 10 percent of cases test positive within three to six months of exposure

When to suspect patient has HIV-AIDS Flu-like Symptoms When a person is first infected by the HIV virus, he typically develops flu-like symptoms. Since the symptoms are typically mild, most people do not seek medical help and, if they do, most doctors don't initially suspect HIV because these symptoms are common for so many diseases.

When to suspect patient has HIV-AIDS However suspicion is raised if its difficult to treat such mild symptoms and is frustrating to the clinician to treat such cases. Patient takes time and relief seems delayed.

When to suspect patient has HIV-AIDS Similarly by passage of some years there may be prolonged fever not responding to routine drugs or a prolonged diarrhoea or weight loss or swollen lymph glands all not responding to routine treatment.

When to suspect patient has HIV-AIDS Clinician finds it difficult to treat such simple cases. It is at this point one should suspect something serious underlying disease patient might be suffering from probably AIDS. Which may be supported by history of sexual promiscuity.

When to suspect patient has HIV-AIDS Or there may be no symptoms at all from the very beginning over many years may be upto 10 years and are not typically aware that they have HIV.

When to suspect patient has HIV-AIDS Finally over years around 10 years patient's CD4 lymphocyte count is fewer than 200 cells per cubic mm of blood, he begins to suffer from so-called opportunistic infections and thus meets the official definition for AIDS. Based on above facts HIV-AIDS can be divided into four stages

Four Stages of HIV

Stage 1 - Primary Short, flu-like illness - occurs one to six weeks after infection Or there may be no symptoms at all Infected person though looking normal can infect other people

Stage 2 - Asymptomatic Lasts for an average of ten years This stage is free from symptoms There may be swollen glands The level of HIV in the blood drops to very low levels HIV antibodies are detectable in the blood

Stage 3 - Symptomatic The symptoms are now moderate more often and prolonged The immune system deteriorates

Stage 4 - HIV  AIDS The immune system weakens The illnesses become more severe leading to emergence of opportunistic infections and cancers A full blown AIDS has developed now

Oesophageal candidiasis Cryptococcal meningitis Chronic cryptosporidial diarrhoea CMV retinitis or colitis Chronic mucocutaneous herpes simplex Disseminated Mycobacterium avium intracellulare Pulmonary or extrapulmonary tuberculosis Pneumocystis carinii (jirovecii) pneumonia AIDS-DEFINING DISEASES

AIDS-DEFINING DISEASES Progressive multifocal leucoencephalopathy Recurrent non-typhi Salmonella septicaemia Cerebral toxoplasmosis Extrapulmonary coccidioidomycosis Invasive cervical cancer Extrapulmonary histoplasmosis Kaposi's sarcoma Non-Hodgkin lymphoma Primary cerebral lymphoma HIV-associated wasting HIV-associated dementia

Oral Candidiasis (thrush)

Opportunistic Oral Yeast Infection by Candida albicans in an AIDS Patient

Chronic Herpes Simplex infection with lesions on tongue and lips. .

Oral Hairy Leukoplakia 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

Kaposi’s sarcoma (KS) Kaposi’s 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.

Extensive tumor lesions of Kaposi's sarcoma in AIDS patient.

Pneumocystis pneumonia X-ray of Pneumocystis jirovecii caused pneumonia. There is increased white (opacity) in the lower lungs on both sides, characteristic of Pneumocystis pneumonia

Pneumocystis pneumonia Pneumocystis pneumonia (originally known as Pneumocystis carinii pneumonia, and still abbreviated as PCP, which now stands for Pneumocystis pneumonia) is relatively rare in healthy, immunocompetent people, but common among HIV-infected individuals. It is caused by Pneumocystis jirovecii.

Non-Hodgkin’s Lymphoma & ascites in AIDS patient

African AIDS patient with slim disease

Blood Detection Tests Enzyme-Linked Immunosorbent Assay/Enzyme Immunoassay (ELISA/EIA) Radio Immunoprecipitation Assay/Indirect Fluorescent Antibody Assay (RIP/IFA) Polymerase Chain Reaction (PCR) Western Blot Confirmatory test

Immunologic Manifestations Antibodies are 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.

ELISA Testing First serological test developed to detect HIV infection. Easy to perform. Easily adapted to batch testing. Highly sensitive and specific. Antibodies detected in ELISA include those directed against: p24, gp120, gp160 and gp41, detected first in infection and appear in most individuals

Western Blot Most popular confirmatory test. Utilizes a lysate prepared from HIV virus. The lysate is electrophoresed to separate out the HIV proteins (antigens). The paper is cut into strips and reacted with test sera. After incubation and washing anti-antibody tagged with radioisotope or enzyme is added. Specific bands form where antibody has reacted with different antigens. Most critical reagent of test is purest quality HIV antigen. The following antigens must be present: p17, p24, p31, gp41, p51, p55, p66, gp120 and gp160.

Western Blot Antibodies to p24 and p55 appear earliest but decrease or become undetectable. Antibodies to gp31, gp41, gp 120, and gp160 appear later but are present throughout all stages of the disease.

Western Blot Interpretation of results. No bands, negative. In order to be interpreted as positive a minimum of 3 bands directed against the following antigens must be present: p24, p31, gp41 or gp120/160. CDC criteria require 2 bands of the following: p24, gp41 or gp120/160.

Western Blot Expensive – $ 80 - 100 technically more difficult visual interpretation lack standardisation - performance - interpretation - indeterminate reactions – resolution of ?? ‘Gold Standard’ for confirmation

Virus isolation Virus isolation can be used to definitively diagnose HIV. Best sample is peripheral blood, but can use CSF, saliva, cervical secretions, semen, tears or material from organ biopsy. Cell growth in culture is stimulated, amplifies number of cells releasing virus. Cultures incubated one month, infection confirmed by detecting reverse transcriptase or p24 antigen in supernatant.

Urine Testing Urine Western Blot As sensitive as testing blood Safe way to screen for HIV Can cause false positives in certain people at high risk for HIV

Oral Testing Orasure The only FDA approved HIV antibody. As accurate as blood testing Draws blood-derived fluids from the gum tissue. NOT A SALIVA TEST!

Indirect immunofluorescence Can be used to detect both virus and antibody to it. Antibody detected by testing patient serum against antigen applied to a slide, incubated, washed and a fluorescent antibody added. Virus is detected by fixing patient cells to slide, incubating with antibody.

Polymerase Chain Reaction (PCR) 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 patient’s HIV DNA if present. Radioactivity is determined.

Virus isolation Virus isolation can be used to definitively diagnose HIV. Best sample is peripheral blood, but can use CSF, saliva, cervical secretions, semen, tears or material from organ biopsy. Cell growth in culture is stimulated, amplifies number of cells releasing virus. Cultures incubated one month, infection confirmed by detecting reverse transcriptase or p24 antigen in supernatant.

Viral Load Tests Viral load or viral burden is the quantity of HIV-RNA that is in the blood. RNA is the genetic material of HIV that contains information to make more virus.

Viral Load Tests Viral load tests measure the amount of HIV-RNA in one milliliter of blood. Take 2 measurements 2-3 weeks apart to determine baseline. Repeat every 3-6 months in conjunction with CD4 counts to monitor viral load ant T-cell count. Repeat 4-6 weeks after starting or changing antiretroviral therapy to determine effect on viral load.

Testing of Neonates Difficult due 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.

To all: CD4 count and Viral load Hepatitis B and C Ab HIVResistant Test Cervical Smear in women Hep A IgG Antibody Toxoplasma Ab Cytomegalovirus Ig G Ab Treponema Serology Genitourinary Medicine Screen INVESTIGATIONS UNDER DIFFERENT CONDITIONS

For CD4 < 200/mm3 CXR HCV-RNA Cryptococcal Ag Stool for Ova ,cyst and parasites. For CD4 < 100/mm3 CMV –PCR Dilated Fundoscopy Electroencephalogram(EEG) Mycobacterial Blood Culture INVESTIGATIONS UNDER DIFFERENT CONDITIONS

Who Should be Treated HIV ELISA positive, confirmed with Western blot HIV RNA >55,000 copies/ml CD4 <350 cells/mm3 Special considerations: Pregnant women Acute HIV infection Exposed healthcare workers

Who Should be Treated Viral load is an indication of the amount of virus in the bloodstream in HIV infection The viral load can also serve as a means to identify when HAART should be started. HAART is commenced when the CD4 cell count is less than 350 cells/mm3, sometimes as low as 200 cells/mm3.

Who Should be Treated Considering starting HAART based on the viral load, however, is not as simple and many doctors may advise patients on HAART with a viral anywhere between 10,000 to 30,000 copies/mL

Who Should be Treated A viral load exceeding 10,000 copies is considered to be high. A viral load below 500 copies/mL is considered as low. However, a level below 500 copies/mL is a good indication that viral replication has drastically slow or ceased.

Who Should be Treated An undetectable viral load is reported when the level drops to below 50 copies/ milliliter. This does not mean that the virus has been eradicated from the bloodstream or that the patient is “cured”.

Who Should be Treated The viral RNA may just be below the threshold and cannot be detected. Eventually the viral load will rise again and regular monitoring even with an undetectable viral load is therefore essential. The aim of treatment is to maintain the viral load at undetectable levels as long as possible.

Who Should be Treated When the CD4 count drops below 200 due to advanced HIV disease, a person is diagnosed with AIDS. A normal range for CD4 cells is between 500 and 1,500. Usually, when a person with low CD4 cells starts HIV medicines, the CD4 cell count increases as the HIV virus is controlled.

Who Should be Treated The same test that measures your CD4 count usually includes a CD8 cell count, too. CD8 cells (also known as CD8+ T cells) are another type of white blood cell that seek out and destroy cells infected with viruses, including HIV-infected cells.

Who Should be Treated CD8 counts in normal person are between 375 and 1100 The ratio of CD4 cells to CD8 cells is often reported. This is calculated by dividing the CD4 value by the CD8 value. In healthy people, this ratio is between 0.9 and 1.9, meaning that there are about 1 to 2 CD4 cells for every CD8 cell. In people with HIV infection, this ratio drops dramatically, meaning that there are many times more CD8 cells than CD4 cells.

When to start drugs to prevent opportunistic infections when CD4 levels are: •Less than 200: Pneumocystis pneumonia (PCP) •Less than 100: toxoplasmosis and cryptococcosis •Less than 75: mycobacterium avium complex (MAC).

Combination Therapy Combination therapy often called HAART is standard care for people with HIV. Monotherapy created virus resistance to the individual drug. Some combination therapies increase the time it takes for the virus to become resistant. Combinations of a PI or NNRTI with one or two NRTI’s is often recommended. Combination therapy may reduce individual drug toxicity by lowering the dosage of each drug

Treatment HAART: Highly Affective Anti-Retro Viral Therapy: Anti-retro viral therapy is recommended if: Patient is asymptomatic/ symptomatic + CD4 count of <350/µl / any AIDS defining condition / plasma HIV RNA greater than 100,000 copies/ml HAART combines two types of antiretroviral drugs: Triple cocktail 2NRTI’S + 1PI or 2NRTI’S + 1NNRTI

Entry inhibitors/Fusion inhibitors: Maraviroc, Enfuvirtide Integrase inhibitors: Raltegravir Maturation Inhibitors under trails: Bevirimat & vivicon Treatment

For needle stick: Post exposure Prophylaxis ZDV+3TC 28 days, but in high risk (high viral RNA copies) a combination of ZDV+3TC+Indinavir Pregnancy: ZDV full dose, trimester 2 and 3+ 6 weeks to neonate reduces vertical transmission by 80% ZDV restricted to intrapartum period + NEVIRAPINE- 1 dose at onset of delivery+ AZT+3TC for 1 week after delivery Neonate: 1 dose of Nevirapine within 24-72 hrs after birth + ZDV for 1 week Symptomatic tx and antibiotics/antivirals/glucocorticoids/thalidomide /antifungals/metronidazole for bacterial, viral, autoimmune, fungal and parasitic infections. Treatment

HAART (highly active antiretroviral therapy) Four approved classes of drugs in the HAART regimens Nucleoside and nucleotide reverse transcriptase inhibitors Non-nucleoside reverse transcriptase inhibitors Protease inhibitors Fusion inhibitors

Currently Available Drugs Nucleoside analogue reverse transcriptase inhibitors Zidovudine Lamivudine Stavudine Didanosine Zalcitabine Abacavir Nucleotide … Tenofovir

Currently Available Drugs Non-nucleoside reverse transcriptase inhibitors Nevirapine Delavridine Efavirenz Fusion Inhibitors Enfuvirtide

Currently Available Drugs Protease Inhibitors Indinavir Nelfinavir Ritonavir Saquinavir soft gel Amprenavir Lopinavir/ritonavir Amprenavir/ritonavir

What is the Best Initial Treatment What we know Two is better than one Three is better than two What we are trying to find out Is four better than three????

Choice of Initial Regimen

Choice of Regimen NNRTIs Nevirapine (2 tab) Efavirenz (3 cap) Delavridine (6 or 12) PIs Indinavir (6 or 12 cap) Nelfinavir (10 tab) Ritonavir (don’t even go there) Saquinavir soft gel (18 cap) Amprenavir (16 cap) Lopinavir/ritonavir (6 cap)

Averting Failure — Promote Adherence HAART has increased long-term survival of patients with HIV Before HAART, median survival: 8 to 10 years After HAART, median survival: may be 36 years Drug “holidays” or treatment interruptions result in rapid viral rebound within 2 to 3 weeks of treatment discontinuation Simplification of dosing regimens to twice or once daily may improve long-term adherence

Summary When to start treatment CD4<350 VL> 55,000 Choice of initial regimen 3 drugs Appropriate prophylaxis Primary: PCP, MAC Secondary: PCP, MAC, Toxo, candidiasis, CMV, etc.

Nucleoside Analogues (NA’s) or NRTI’s

Nucleotide Analogues Tenofovir Dose: 300 mg once daily Take with food for optimal absorption

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI’s)

Protease Inhibitors (PI’s)

Some Alternative Therapies Virus adsorption inhibitors – interfere with virus binding to cell surface by shielding the positively charged sites on the gp-120 glycoprotein Polyanionic compounds Viral co receptor antagonists – compete for binding at the CXCR4 (X4) and CCR5 (R5) coreceptors bicyclams and ligands

HIV Occupational Exposure Review facility policy and report the incident Medical follow-up is necessary to determine the exposure risk and course of treatment Baseline and follow-up HIV testing Four week course of medication initiated one to two hours after exposure AZT (200mg)-TID +lamivudine(3TC)(150mg)BID x 4days Nelfinavir (750 mg) TID ,AZT/3TC Exposure precautions practiced

Why Does Treatment Fail? Intolerance Infection with a resistant virus Malabsorption NON-ADHERENCE TOPS THE LIST Rates of adherence have a direct correlation with success of HAART1 Near perfect viral suppression in DOT trials2

Averting Failure — Promote Adherence HAART has increased long-term survival of patients with HIV Before HAART, median survival: 8 to 10 years After HAART, median survival: may be 36 years Drug “holidays” or treatment interruptions result in rapid viral rebound within 2 to 3 weeks of treatment discontinuation Simplification of dosing regimens to twice or once daily may improve long-term adherence

Prevention and control of HIV Education Prevention of blood born HIV transmission Anti Retro Viral treatment Combination therapy Post exposure prophylaxis Specific prophylaxis Primary health care

Four ways to protect yourself? Abstinence Monogamous Relationship Protected Sex Sterile needles

Protected Sex Use condoms (female or male) every time you have sex (vaginal or anal) Always use latex or polyurethane condom (not a natural skin condom) Always use a latex barrier during oral sex

When Using A Condom Remember To: Make sure the package is not expired Make sure to check the package for damages Do not open the package with your teeth for risk of tearing Never use the condom more than once Use water-based rather than oil-based condoms

THANK YOU There is no end to education. It is not that you read a book, pass an examination, and finish with education. The whole of life, from the moment you are born to the moment you die, is a process of learning.

Thank You again Any question ? or Doubt ! EMAIL AT- (drbashir123@gmail.com)