World AIDS Day: All You Need To Know About HIV/AIDS

Introduction

HIV/AIDS was first reported in the United States in 1981. The disease which is a global epidemic has now infected more than 30 million people worldwide. In some African countries over 20% of the population is infected. The epidemic is growing most rapidly among minority populations and is a leading killer in many African countries.

Infection in the female population has risen, now being recognized as the fourth leading cause of death in women and one of the leading causes of death in male adults 25 – 44 years of age. More than 50% of the reported AIDS  cases were among men with homosexual and bisexual contacts, but this percentage has been declining over the past two years, the impact on mortality being noticed in larger metropolitan areas, but is also heading towards smaller areas worldwide. Anyone can be infected; it is no longer affecting just one specific portion of the population. At this time there is still no cure for HIV.

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Meaning of AIDS

AIDS stands for:

  • ACQUIRED which means: you were not born with the disease compared to most immune deficient conditions. You can only be born with AIDS if your mother had AIDS when pregnant.
  • IMMUNE DEFICIENCY which means: the disease is characterized by a weakened or ineffective immune system with no resistance to infections.
  • SYNDROME which means: AIDS is a combination of signs and symptoms which occur together due to the HIV infection as well as many other infections as a result of the immune deficiency.

HIV stands for Human Immunodeficiency Virus; the virus causes AIDS, and is an infection of the immune system which destroys the body’s ability to fight off infections. HIV may also enter a cell then remain quiet for a long time and drug therapy only destroys the active virus. HIV infects the cells (T Lymphocytes) of the immune system weakening the entire system. The definition of AIDS relates to CD4+ T-cells count. Healthy adults usually have CD4+ T-cell counts of 1,000 or more. AIDS and some HIV sufferers have less than 200 CD4+ T-cells.

Clinical Conditions

There are over 26 clinical conditions affecting people with advanced HIV disease. These conditions are usually opportunistic infections, which can sometimes be fatal because the immune system is so damaged by HIV that it is unable to fight off certain bacteria, viruses and other microbes.

HIV has been located in fluids such as blood, breast milk, saliva, semen, tears, and vaginal fluids. However, it appears that the disease can principally be transmitted through blood, blood products, and sexual fluids. People can be infected and NOT look sick or even have AIDS but can still transmit HIV. This is a problem for drug therapy because drugs destroy the virus while it is active.

 

Transmission

The AIDS virus is transmitted from one person to another through several methods:

  • Blood
    • Accidents in health care (i.e., needle stick or other medical instruments)
    • Ear piercing
    • Needle sharing with an infected person for any reason (IV drug needles [only minute amounts of blood are needed]
    • Receiving a blood transfusion with infected blood
    • Prior to 1985 HIV was frequently transmitted by blood transfusions because there was no effective way to test blood for the AIDS virus.
  • Contact with infected blood
    • HIV was transmitted through transfusions of contaminated blood or blood components, prior to the screening of blood for HIV infection and before the introduction in 1985 of heat-treating techniques to destroy HIV in blood products. The risk of acquiring HIV from transfusions today is extremely small.
  • Sexual Contact
    • The virus can be spread in: Artificial insemination with semen from an infected person; Body fluids including sperm; Oral sex
    • The infection can be spread from unprotected sex  (sex without condoms) with an infected partner, including: anal intercourse; oral intercourse; vaginal intercourse;
    • The infection can be spread from: men to men; men to women; women to men; women to women
    • The virus can enter the body during sex through the: lining of the vagina; mouth; penis; rectum; vulva
    • You are also at risk if you have another sexually transmitted disease such as: Bacterial Vaginosis; Chlamydia; Gonorrhoea; Herpes; Syphilis as you are more susceptible to acquiring HIV infection during sex with an infected partner
  • HIV has been detected in the saliva of infected individuals, however, no evidence exists that the virus is spread by contact with saliva. Tests show saliva has natural compounds that inhibit the infectiousness of HIV. No evidence has been found that the virus is spread to others through saliva such as by kissing. No one knows, however, the risk of infection from so-called “deep” kissing, involving the exchange of large amounts of saliva.
  • HIV has not been found to spread through: faces, sweat, tears, urine
  • Families of HIV-infected people have shown clearly that HIV is not spread through Casual Contact such as: biting insects such as mosquitoes or bedbugs; sharing of bedding; sharing of food utensils; sharing of towels; swimming pools; telephones
  • There is no risk of transmission through: Donating blood when sterile needles are used; Embracing or cuddling; Kissing without exchange of saliva; Sharing utensils; Touching an HIV infected person; or through touching objects such as clothes, door knobs, toilet seats
  • HIV can be spread from Mother to infant during: Birth (Peripartum), Breast feeding, Pregnancy (Intrauterine)
  • Treating Pregnant Mothers (PMTCT): During pregnancy or birth women can transmit HIV to their foetuses. Approximately 1/4 to 1/3 of all untreated pregnant women infected with HIV will pass the infection to their babies, but it can also be spread to babies through the breast milk of infected mothers.
  • Help Factors
    • Anti-HIV drugs are very effective in limiting transmission to infants but some transmission still occurs
    • The risk of transmission further diminishes with a Caesarean section
    • The drug AZT taken during pregnancy reduces significantly the chance of transmitting HIV to the baby
    • AZT treatment of mothers combined with caesarean sectioning to deliver infants reduces infection rates to 1%
  • Babies born to mothers infected with HIV:
  • may or may not be infected with the virus
  • share their mothers’ antibodies to HIV for several months
  • If these babies lack symptoms, a definitive diagnosis of HIV infection using standard antibody tests cannot be made until after 15 months of age. By this age babies are unlikely to still carry their mothers’ antibodies and will have produced their own if they are infected.
  • New technologies are being used to detect HIV infection in infants (3-15 months).  A number of blood tests are being used to detect the virus in babies younger than 3 months.

 

Symptoms

Opportunistic infections common in people with AIDS cause such symptoms as: abdominal cramps, coma, coughing, difficult or painful swallowing, extreme fatigue, fever, lack of coordination, mental symptoms such as confusion and forgetfulness, ulcers in the genital region, nausea, pelvic inflammatory disease, persistent or frequent yeast infections (oral or vaginal), persistent skin rashes or flaky skin, seizures, severe and persistent diarrhoea, severe headaches, shortness of breath, sore throat, swollen lymph glands, weight loss, vision loss, vomiting; as well as severe Herpes infections causing anal sores, genital sores, mouth sores, and Shingles (a painful nerve disease).

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Children with AIDS are prone to the same opportunistic infections as adults, but as well experience severe forms of bacterial infections such as conjunctivitis (pink eye), ear infections, tonsillitis; as well as delayed development or failure to thrive.

 

AIDS sufferers commonly develop various cancers such as cervical cancer and Kaposi’s sarcoma as well as cancers of the immune system (lymphomas) which are more aggressive and difficult to treat in AIDS sufferers and which appear in light-skinned people as round brown, reddish or purple spots which develop in the skin or in the mouth. In dark-skinned people the spots are more pigmented.

 

People with AIDS may experience phases of intense life-threatening illness followed by phases of normal functioning. However, many people are too debilitated by the symptoms of AIDS to hold steady employment or do household chores.

HIV infection is also associated with an acute illness in most infected persons. This illness, called acute HIV infection begins within 1-3 weeks of exposure, and usually involves a combination of symptoms. The symptoms are often mistaken for those of other viral infection. After that the symptoms may not surface for years in adults, or within 2 years in children born with HIV. The period of asymptomatic infection is highly variable with some people; beginning symptoms within a few months, having no symptoms for 10 years or more, or having symptoms resolve themselves within 1-3 weeks. During the asymptomatic period HIV actively multiplies infecting and killing immune system cells and causing a decline in blood levels of CD4+ T cells (T4 cells).

 

Stages of HIV Infection

Acute HIV Syndrome: this is the first stage of seroconversion. The virus rapidly spreads to organs, especially the lymphoid tissues. However, the HIV virus is not very aggressive in causing diseases or severe symptoms.

Asymptomatic State: the infection is latent. The virus starts to grow and multiply in the lymph nodes.

Symptomatic Disease/AIDS: there is viraemia (spread of virus in the blood) and Loss of immune system, mainly due to infection of CD4+ T-Lymphocytes.

End stage Disease: the immune system collapses and the virus continues to slowly destroy the immune system for up to 10 years but usually an opportunistic infection is the cause of death.

 Conditions relating to HIV

Bacillary-Angiomatosis
Bacillary-Angiomatosis

 

Viral infections: Herpes Simplex, Human papillomavirus, Molluscum Contagiosum, Varicella zoster

Fungal infections: Candidiasis, Dermatophyte infections, Pityrosporum Folliculitis

Inflammatory Conditions: Eczema, Psoriasis, Seborrhoeic Dermatitis

Malignancies: Kaposi’s sarcoma, Lymphomas

Others: Bacillary angiomatosis, drug eruptions, non-specific hair and nail changes, non-specific folliculitis, Scabies

 

Diagnosis

The AIDS test is a test that measures the immune response to HIV, consisting of antibodies that are generated in response to the infection.

Standard AIDS Test: The Standard AIDS Test measures antibodies.  These take time to develop, so in the very early stages of infection there may be a negative antibody test even though the person can be infected. Tests should be carried out on anyone who had a blood transfusion before 1985; anyone who has had unprotected sex with an infected person; or infants of infected mothers.

The standard blood test for HIV is negative in persons with acute HIV infection, so a special blood test has to be used if this diagnosis is suspected. There are two tests to diagnose acute HIV infection; namely, HIV viral load and HIV p24 antigen tests. These tests should be carried out on persons who have had a known exposure to the infection through sharing needles, unprotected sex; and on persons who have symptoms of acute HIV infection. The standard blood test becomes positive about 4-6 weeks after infection.

HIV is mainly detected by testing a blood sample for the presence of antibodies to HIV which generally do not reach detectable levels until 1-3 months following infection, sometimes taking up to 6 months to be generated in large enough quantities to show up in standard blood tests.

HIV testing can also carried out on samples of saliva and urine.

Early testing for HIV infection should be carried out as soon as antibodies to the virus develop to enable appropriate treatment to be received when they are most able to combat HIV; the emergence of certain opportunistic infections to be prevented; HIV-infected people to be alerted on high-risk behaviours that could spread HIV to others to be avoided.

Two different types of antibody tests are used to diagnose HIV infection; namely, Enzyme-linked Immunosorbent Assay (ELISA) and Western Blot. If a person is highly likely to be infected with HIV and yet both tests are negative, a test for the presence of HIV itself in the blood may be carried out, with a repeat antibody testing at a later date, when antibodies to HIV are more likely to have developed.

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Treatment

When AIDS first surfaced, no drugs were available to combat the underlying immune deficiency and few treatments existed for the opportunistic diseases that resulted. However, therapies have now been developed to fight both HIV infection and its associated infections and cancers. There are a number of drugs approved for the treatment of HIV infection including Abacavir Succinate, Nucleoside Analog Reverse Transcriptase inhibitors (NRTIs), Didanosine (ddI), Lamivudine (3TC), Stavudine (D4T), Zalcitabine (ddC), and Zidovudine (also known as AZT). These drugs slow the spread of HIV and delay the onset of opportunistic infections. The drugs do not prevent transmission of HIV to other individuals.

Also available for use in combination with other antiretroviral drugs during stages of HIV infection are Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) such as Delavirdine, Efavirenz, and Nevirapine.

Virus replication is interrupted at a later step by anti-HIV drugs, called protease inhibitors such as Indinavir, Nelfinavir, Ritonavir, and Saquinivir.

HIV can become resistant to each class of drugs, so a combination treatment using both is necessary to effectively lower the amount of virus in the blood. It appears this cocktail will no longer result in complete eradication of the virus. Persons who have stopped the drug cocktail even after two years of treatment have generally had a rapid return of the virus.

Antiretroviral drugs do not cure HIV infection or AIDS and can have severe side effects. AZT may cause red or white blood cell depletion, especially when taken in the later stages of the disease. If the loss of blood cells is severe treatment with AZT must be discontinued. DdI can cause diarrhoea, gastrointestinal disorders associated with protease inhibitors, nausea, painful nerve damage, and pancreas inflammation. Protease inhibitors can interact with other drugs resulting in serious side effects such as abnormal redistribution of body fat among some individuals receiving protease inhibitors.

Drugs available to treat opportunistic infections include Foscarne and Ganciclovir used to treat cytomegalovirus eye infections; Fluconazole used to treat yeast and other fungal infections; Pentamidine and TMP/SMX used to treat Pneumocystis carinii pneumonia (PCP). Adults with HIV whose CD4+ T-cell counts drop below 200 are given treatment to prevent the occurrence of PCP. Children are given PCP preventive therapy when their CD4+ T-cell counts drop to levels considered below normal for their age group.

Prevention

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Because many people infected with HIV have no symptoms, it is not known with certainty whether a sexual partner is infected unless he/she has been tested repeatedly for the virus or has not engaged in any risky behaviour. The main preventive measures are abstinence from sex; use of male latex condoms whenever having oral, anal or vaginal sex; and water-based lubricants should be used with latex condoms. Some spermicides can also kill HIV organisms.

Patrick Fynn

Patrick Fynn is the moderator and author of the Medical Practitioners forum.

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