rhdfthtrfhHuman immunodeficiency virus infection / acquired immunodeficiency

syndrome (HIV/AIDS) is a disease of the human immune system caused by infection with human
immunodeficiency virus (HIV).
[1]
During the initia infection! a "erson may e#"erience a brief "eriod
of infuen$a%i&e iness. 'his is ty"icay foowed by a "roonged "eriod without sym"toms. (s the
iness "rogresses! it interferes more and more with the immune system! ma&ing the "erson much
more i&ey to get infections! incuding o""ortunistic infections and tumors that do not usuay affect
"eo"e who have wor&ing immune systems.
HIV is transmitted "rimariy via un"rotected se#ua intercourse (incuding ana and ora se#)!
contaminated bood transfusions! hy"odermic needes! and from mother to chid during "regnancy!
deivery! or breastfeeding.
[)]
*ome bodiy fuids! such as saiva and tears! do not transmit HIV.
[+]
,revention of HIV infection! "rimariy through safe se# andneede%e#change "rograms! is a &ey
strategy to contro the s"read of the disease. 'here is no cure or vaccine- however! antiretrovira
treatment can sow the course of the disease and may ead to a near%norma ife e#"ectancy. .hie
antiretrovira treatment reduces the ris& of death and com"ications from the disease! these
medications are e#"ensive and have side effects. .ithout treatment! the average surviva time after
infection with HIV is estimated to be / to 11 years! de"ending on the HIV subty"e.
[0]
1enetic research indicates that HIV originated in west%centra (frica during the ate nineteenth or
eary twentieth century.
[2]
(ID* was first recogni$ed by the 3nited *tates 4enters for Disease 4ontro
and ,revention (4D4) in 1/51 and its cause6HIV infection6was identified in the eary "art of the
decade.
[7]
*ince its discovery! (ID* has caused an estimated +7 miion deaths wordwide (as of
)81)).
[9]
(s of )81)! a""ro#imatey +2.+ miion "eo"e are iving with HIV gobay.
[9]
HIV/(ID* is
considered a "andemic6a disease outbrea& which is "resent over a arge area and is activey
s"reading.
[5]
HIV/(ID* has had a great im"act on society! both as an iness and as a source of discrimination.
'he disease aso has significant economic im"acts. 'here are manymisconce"tions about
HIV/(ID* such as the beief that it can be transmitted by casua non%se#ua contact. 'he disease
has aso become sub:ect to manycontroversies invoving reigion. It has attracted internationa
medica and "oitica attention as we as arge%scae funding since it was identified in the 1/58s
Acute infection
;ain sym"toms of acute HIV infection
'he initia "eriod foowing the contraction of HIV is caed acute HIV! "rimary HIV or acute retrovira
syndrome. ;any individuas deveo" an infuen$a%i&e iness or a mononuceosis%i&e iness )<0
wee&s "ost e#"osure whie others have no significant sym"toms.
[1+][10]
*ym"toms occur in 08</8= of
cases and most commony incude fever!arge tender ym"h nodes! throat infammation! a rash!
headache! and/or sores of the mouth and genitas. 'he rash! which occurs in )8<28= of cases!
"resents itsef on the trun& and is macuo"a"uar! cassicay.*ome "eo"e aso
deveo" o""ortunistic infections at this stage. 1astrointestina sym"toms such as nausea! vomiting
ordiarrhea may occur! as may neuroogica sym"toms of "eri"hera neuro"athy or 1uiain%>arre
syndrome.
]
'he duration of the sym"toms varies! but is usuay one or two wee&s
Due to their nons"ecific character! these sym"toms are not often recogni$ed as signs of HIV
infection. ?ven cases that do get seen by a famiy doctor or a hos"ita are often misdiagnosed as
one of the many common infectious diseases with overa""ing sym"toms. 'hus! it is recommended
that HIV be considered in "eo"e "resenting an une#"ained fever who may have ris& factors for the
infection
Acquired immunodeficiency syndrome
;ain sym"toms of (ID*.
(c@uired immunodeficiency syndrome ((ID*) is defined in terms of either a 4D0
A
' ce count beow
)88 ces "er BC or the occurrence of s"ecific diseases in association with an HIV infection. In the
absence of s"ecific treatment! around haf of "eo"e infected with HIV deveo" (ID* within ten
years.
[
'he most common initia conditions that aert to the "resence of (ID* are "neumocystis
"neumonia (08=)! cache#ia in the form of HIV wasting syndrome ()8=) and eso"hagea
candidiasis. Dther common signs incude recurring res"iratory tract infections.
[

D""ortunistic infections may be caused by bacteria! viruses! fungi and "arasites that are normay
controed by the immune system.
[
.hich infections occur "arty de"ends on what organisms are
common in the "ersonEs environment. 'hese infections may affect neary every organ system.
,eo"e with (ID* have an increased ris& of deveo"ing various vira induced cancers
incuding Fa"osiEs sarcoma!>ur&ittEs ym"homa! "rimary centra nervous system ym"homa!
and cervica cancer. Fa"osiEs sarcoma is the most common cancer occurring in 18 to )8= of "eo"e
with HIV. 'he second most common cancer is ym"homa which is the cause of death of neary 17=
of "eo"e with (ID* and is the initia sign of (ID* in + to 0=.>oth these cancers are associated
with human her"esvirus 5.
[
4ervica cancer occurs more fre@uenty in those with (ID* due to its
association with human "a"iomavirus (H,V)
(dditionay! "eo"e with (ID* fre@uenty have systemic sym"toms such as "roonged
fevers! sweats ("articuary at night)! swoen ym"h nodes! chis! wea&ness! and weight oss.
Diarrhea is another common sym"tom "resent in about /8= of "eo"e with (ID*. 'hey can aso be
affected by diverse "sychiatric and neuroogica sym"toms inde"endent of o""ortunistic infections
and cancers.
Transmission
HIV is transmitted by three main routesG se#ua contact! e#"osure to infected body fuids or tissues!
and from mother to chid during "regnancy! deivery! or breastfeeding (&nown as vertica
transmission). 'here is no ris& of ac@uiring HIV if e#"osed to feces! nasa secretions! saiva! s"utum!
sweat! tears! urine! or vomit uness these are contaminated with bood. It is "ossibe to be co%
infected by more than one strain of HIV6a condition &nown as HIV su"erinfection.
Sexual
'he most fre@uent mode of transmission of HIV is through se#ua contact with an infected
"erson. 'he ma:ority of a transmissions wordwide occur through heterose#ua contacts (i.e. se#ua
contacts between "eo"e of the o""osite se#)- however! the "attern of transmission varies
significanty among countries. In the 3nited *tates! as of )88/! most se#ua transmission occurred
in men who had se# with men with this "o"uation accounting for 70= of a new cases.
(s regards un"rotected heterose#ua contacts! estimates of the ris& of HIV transmission "er se#ua
act a""ear to be four to ten times higher in ow%income countries than in high%income countries. In
ow%income countries! the ris& of femae%to%mae transmission is estimated as 8.+5= "er act! and of
mae%to%femae transmission as 8.+8= "er act- the e@uivaent estimates for high%income countries
are 8.80= "er act for femae%to%mae transmission! and 8.85= "er act for mae%to%femae
transmission. 'he ris& of transmission from ana intercourse is es"eciay high! estimated as 1.0<
1.9= "er act in both heterose#ua and homose#ua contacts. .hie the ris& of transmission from ora
se# is reativey ow! it is sti "resent. 'he ris& from receiving ora se# has been described as Hneary
niHhowever a few cases have been re"orted. 'he "er%act ris& is estimated at 8<8.80= for rece"tive
ora intercourse. In settings invoving "rostitution in ow income countries! ris& of femae%to%mae
transmission has been estimated as ).0= "er act and mae%to%femae transmission as 8.82= "er
act.
Iis& of transmission increases in the "resence of many se#uay transmitted infections and genita
ucers. 1enita ucers a""ear to increase the ris& a""ro#imatey fivefod. Dther se#uay transmitted
infections! such as gonorrhea! chamydia! trichomoniasis! and bacteria vaginosis! are associated
with somewhat smaer increases in ris& of transmission.
'he vira oad of an infected "erson is an im"ortant ris& factor in both se#ua and mother%to%chid
transmission. During the first ).2 months of an HIV infection a "ersonEs infectiousness is tweve
times higher due to this high vira oadI of the "erson is in the ate stages of infection! rates of
transmission are a""ro#imatey eightfod greater.
[

4ommercia se# wor&ers (incuding those in "ornogra"hy) have an increased rate of HIV. Iough
se# can be a factor associated with an increased ris& of transmission. *e#ua assaut is aso
beieved to carry an increased ris& of HIV transmission as condoms are rarey worn! "hysica trauma
to the vagina or rectum is i&ey! and there may be a greater ris& of concurrent se#uay transmitted
infections.
Body fluids
4D4 "oster from 1/5/ highighting the threat of (ID* associated with drug use
'he second most fre@uent mode of HIV transmission is via bood and bood "roducts.
[)]
>ood%borne
transmission can be through neede%sharing during intravenous drug use! neede stic& in:ury!
transfusion of contaminated bood or bood "roduct! or medica in:ections with unsteriised
e@ui"ment. 'he ris& from sharing a neede during drug in:ection is between 8.7+ and ).0= "er act!
with an average of 8.5=. 'he ris& of ac@uiring HIV from a neede stic& from an HIV%infected "erson
is estimated as 8.+= (about 1 in +++) "er act and the ris& foowing mucus membrane e#"osure to
infected bood as 8.8/= (about 1 in 1888) "er act. In the 3nited *tates intravenous drug users made
u" 1)= of a new cases of HIV in )88/!
]
and in some areas more than 58= of "eo"e who in:ect
drugs are HIV "ositive.
HIV is transmitted in about /+= of bood transfusions invoving infected bood. In deveo"ed
countries the ris& of ac@uiring HIV from a bood transfusion is e#tremey ow (ess than one in haf a
miion) where im"roved donor seection and HIV screening is "erformed- for e#am"e! in the 3F the
ris& is re"orted at one in five miion. In ow income countries! ony haf of transfusions may be
a""ro"riatey screened (as of )885)! and it is estimated that u" to 12= of HIV infections in these
areas come from transfusion of infected bood and bood "roducts! re"resenting between 2= and
18= of goba infections.
3nsafe medica in:ections "ay a significant roe in HIV s"read in sub%*aharan (frica. In )889!
between 1) and 19= of infections in this region were attributed to medica syringe use. 'he .ord
Heath Drganisation estimates the ris& of transmission as a resut of a medica in:ection in (frica at
1.)=. *ignificant ris&s are aso associated with invasive "rocedures! assisted deivery! and denta
care in this area of the word.
,eo"e giving or receiving tattoos! "iercings! and scarification are theoreticay at ris& of infection but
no confirmed cases have been documented. It is not "ossibe for mos@uitoes or other insects to
transmit HIV.
Mother-to-child
HIV can be transmitted from mother to chid during "regnancy! during deivery! or through breast
mi&. 'his is the third most common way in which HIV is transmitted gobay. In the absence of
treatment! the ris& of transmission before or during birth is around )8= and in those who aso
breastfeed +2=.(s of )885! vertica transmission accounted for about /8= of cases of HIV in
chidren. .ith a""ro"riate treatment the ris& of mother%to%chid infection can be reduced to about
1=. ,reventive treatment invoves the mother ta&ing antiretrovira during "regnancy and deivery! an
eective caesarean section! avoiding breastfeeding! and administering antiretrovira drugs to the
newborn. ;any of these measures are however not avaiabe in the deveo"ing word. If bood
contaminates food during "re%chewing it may "ose a ris& of transmission.
HIV testing
;ost "eo"e infected with HIV deveo" s"ecific antibodies (i.e. seroconvert) within three to tweve
wee&s of the initia infection. Diagnosis of "rimary HIV before seroconversion is done by measuring
HIV%IJ( or ")0 antigen. ,ositive resuts obtained by antibody or ,4I testing are confirmed either
by a different antibody or by ,4I.
(ntibody tests in chidren younger than 15 months are ty"icay inaccurate due to the continued
"resence ofmaterna antibodies 'hus HIV infection can ony be diagnosed by ,4I testing for HIV
IJ( or DJ(! or via testing for the ")0 antigen. ;uch of the word ac&s access to reiabe ,4I
testing and many "aces sim"y wait unti either sym"toms deveo" or the chid is od enough for
accurate antibody testing. In sub%*aharan (frica as of )889<)88/ between +8 and 98= of the
"o"uation was aware of their HIV status. In )88/! between +.7 and 0)= of men and women in *ub%
*aharan countries were tested which re"resented a significant increase com"ared to "revious years.
lassifications of HIV infection
'wo main cinica staging systems are used to cassify HIV and HIV%reated disease
for surveiance "ur"osesG the .HD disease staging system for HIV infection and disease!
[1)]
and
the 4D4 cassification system for HIV infection.
[58]
'he 4D4Es cassification system is more
fre@uenty ado"ted in deveo"ed countries. *ince the.HDEs staging system does not re@uire
aboratory tests! it is suited to the resource%restricted conditions encountered in deveo"ing
countries! where it can aso be used to he" guide cinica management. Des"ite their differences!
the two systems aow com"arison for statistica "ur"oses.
[18][1)][58]
'he .ord Heath Drgani$ation first "ro"osed a definition for (ID* in 1/57.
[1)]
*ince then! the .HD
cassification has been u"dated and e#"anded severa times! with the most recent version being
"ubished in )889.
[1)]
'he .HD system uses the foowing categoriesG
,rimary HIV infectionG ;ay be either asym"tomatic or associated with acute retrovira
syndrome.
[1)]
*tage IG HIV infection is asym"tomatic with a 4D0
A
' ce count (aso &nown as 4D0 count)
greater than 288 "er microitre (B or cubic mm) of bood.
[1)]
;ay incude generai$ed ym"h node
enargement.
[1)]
*tage IIG ;id sym"toms which may incude minor mucocutaneous manifestations and
recurrent u""er res"iratory tract infections. ( 4D0 count of ess than 288/B.
[1)]
*tage IIIG (dvanced sym"toms which may incude une#"ained chronic diarrhea for onger
than a month! severe bacteria infections incuding tubercuosis of the ung! and a 4D0 count of
ess than +28/B.
[1)]
*tage IV or (ID*G severe sym"toms which incude to#o"asmosis of the brain! candidiasis of
the eso"hagus! trachea! bronchi or ungs and Fa"osiEs sarcoma. ( 4D0 count of ess than
)88/B.
[1)]
'he 3nited *tates 4enter for Disease 4ontro and ,revention aso created a cassification system for
HIV! and u"dated it in )885.
[58]
'his system cassifies HIV infections based on 4D0 count and cinica
sym"toms!
[58]
and describes the infection in three stagesG
*tage 1G 4D0 count K 288 ces/B and no (ID* defining conditions
*tage )G 4D0 count )88 to 288 ces/B and no (ID* defining conditions
*tage +G 4D0 count L )88 ces/B or (ID* defining conditions
3n&nownG if insufficient information is avaiabe to ma&e any of the above cassifications
Mor surveiance "ur"oses! the (ID* diagnosis sti stands even if! after treatment! the 4D0
A
' ce
count rises to above )88 "er BC of bood or other (ID*%defining inesses are cured.
[18]
Prevention
Main article: Prevention of HIV/AIDS
(ID* 4inic! ;cCeod 1an:! Himacha ,radesh! India! )818
Sexual contact
4onsistent condom use reduces the ris& of HIV transmission by a""ro#imatey 58= over the ong
term.
[51]
.hen condoms are used consistenty by a cou"e in which one "erson is infected! the rate of
HIV infection is ess than 1= "er year.
[5)]
'here is some evidence to suggest that femae
condoms may "rovide an e@uivaent eve of "rotection.
[5+]
(""ication of a vagina ge
containing tenofovir (a reverse transcri"tase inhibitor) immediatey before se# seems to reduce
infection rates by a""ro#imatey 08= among (frican women.
[50]
>y contrast! use of
the s"ermicide nono#yno%/ may increase the ris& of transmission due to its tendency to cause
vagina and recta irritation.
[52]
4ircumcision in *ub%*aharan (frica Hreduces the ac@uisition of HIV by
heterose#ua men by between +5= and 77= over )0 monthsH.
[57]
>ased on these studies! the .ord
Heath Drgani$ation and 3J(ID* both recommended mae circumcision as a method of "reventing
femae%to%mae HIV transmission in )889.
[59]
.hether it "rotects against mae%to%femae transmission
is dis"uted
[55][5/]
and whether it is of benefit in deveo"ed countries and among men who have se#
with men is undetermined.
[/8][/1][/)]
*ome e#"erts fear that a ower "erce"tion of vunerabiity among
circumcised men may cause more se#ua ris&%ta&ing behavior! thus negating its "reventive effects.
[/+]
,rograms encouraging se#ua abstinence do not a""ear to affect subse@uent HIV ris&.
[/0]
?vidence
for a benefit from "eer education is e@uay "oor.
[/2]
4om"rehensive se#ua education "rovided at
schoo may decrease high ris& behavior.
[/7]
( substantia minority of young "eo"e continues to
engage in high%ris& "ractices des"ite &nowing about HIV/(ID*! underestimating their own ris& of
becoming infected with HIV.
[/9]
It is not &nown whether treating other se#uay transmitted infections
is effective in "reventing HIV.
[0)]
!re-ex"osure
'reating "eo"e with HIV whose 4D0 count K +28ces/BC with antiretroviras "rotects /7= of their
"artners from infection.
[/5]
'his is about a 18 to )8 fod reduction in transmission ris&.
[//]
,re%e#"osure
"ro"hya#is (,r?,) with a daiy dose of the medications tenofovir! with or without emtricitabine! is
effective in a number of grou"s incuding men who have se# with men! cou"es where one is HIV
"ositive! and young heterose#uas in (frica.
[50]
It may aso be effective in intravenous drug users with
a study finding a decrease in ris& of 8.9 to 8.0 "er 188 "erson years.
[188]
3niversa "recautions within the heath care environment are beieved to be effective in decreasing
the ris& of HIV.
[181]
Intravenous drug use is an im"ortant ris& factor and harm reduction strategies
such as neede%e#change "rogrammes and o"ioid substitution thera"y a""ear effective in
decreasing this ris&.
[18)][18+]
!ost-ex"osure
( course of antiretroviras administered within 05 to 9) hours after e#"osure to HIV%"ositive bood or
genita secretions is referred to as "ost%e#"osure "ro"hya#is(,?,).
[180]
'he use of the singe
agent $idovudine reduces the ris& of a HIV infection five%fod foowing a neede%stic& in:ury.
[180]
(s of
)81+! the "revention regimen recommended in the 3nited *tates consists of three medications6
tenofovir! emtricitabine and rategravir6as this may reduce the ris& further.
[182]
,?, treatment is recommended after a se#ua assaut when the "er"etrator is &nown to be HIV
"ositive! but is controversia when their HIV status is un&nown.
[187]
'he duration of treatment is usuay
four wee&s
[189]
and is fre@uenty associated with adverse effects6where $idovudine is used! about
98= of cases resut in adverse effects such as nausea ()0=)! fatigue ())=)! emotiona distress
(1+=) and headaches (/=).
[)/]
Mother-to-child
,rograms to "revent the vertica transmission of HIV (from mothers to chidren) can reduce rates of
transmission by /)<//=.
[22][18)]
'his "rimariy invoves the use of a combination of antivira
medications during "regnancy and after birth in the infant and "otentiay incudes botte
feeding rather than breastfeeding.
[22][185]
If re"acement feeding is acce"tabe! feasibe! affordabe!
sustainabe! and safe! mothers shoud avoid breastfeeding their infants- however e#cusive
breastfeeding is recommended during the first months of ife if this is not the case.
[18/]
If e#cusive
breastfeeding is carried out! the "rovision of e#tended antiretrovira "ro"hya#is to the infant
decreases the ris& of transmission.
[118]
Vaccination
Main article: HIV vaccine
(s of )81) there is no effective vaccine for HIV or (ID*.
[111]
( singe tria of the vaccine IV
100 "ubished in )88/ found a "artia reduction in the ris& of transmission of roughy +8=!
stimuating some ho"e in the research community of deveo"ing a truy effective vaccine.
[11)]
Murther
trias of the IV 100 vaccine are ongoing.
[11+][110]
Management
Main article: Management of HIV/AIDS
'here is currenty no cure or effective HIV vaccine. 'reatment consists of high active antiretrovira
thera"y (H((I') which sows "rogression of the disease
[112]
and as of )818 more than 7.7 miion
"eo"e were ta&ing them in ow and midde income countries.
[117]
'reatment aso incudes "reventive
and active treatment of o""ortunistic infections.
Antiviral thera"y
Abacavir < a nuceoside anaog reverse transcri"tase inhibitor (J(I'I or JI'I)
4urrent H((I' o"tions are combinations (or Hcoc&taisH) consisting of at east three medications
beonging to at east two ty"es! or Hcasses!H of antiretrovira agents.
[119]
Initiay treatment is ty"icay
a non%nuceoside reverse transcri"tase inhibitor(JJI'I) "us two nuceoside anaogue reverse
transcri"tase inhibitors (JI'Is).
[115]
'y"ica JI'Is incudeG $idovudine ((N') or tenofovir ('DM)
and amivudine (+'4) or emtricitabine (M'4).
[115]
4ombinations of agents which incude a "rotease
inhibitors (,I) are used if the above regimen oses effectiveness.
[119]
.hen to start antiretrovira thera"y is sub:ect to debate.
[12][11/]
'he .ord Heath Drgani$ation
recommends antiretroviras in a adoescents! aduts and "regnant women with a 4D0 count ess
than 288/B with this being es"eciay im"ortant in those with counts ess than +28/B or those with
sym"toms regardess of 4D0 count.
[115]
'his is su""orted by the fact that beginning treatment at this
eve reduces the ris& of death.
[1)8]
'he 3nited *tates in addition recommends them for a HIV%
infected "eo"e regardess of 4D0 count or sym"toms- however it ma&es this recommendation with
ess confidence for those with higher counts.
[1)1]
.hie the .HD aso recommends treatment in
those who are co%infected with tubercuosis and those with chronic active he"atitis >.
[119]
Dnce
treatment is begun it is recommended that it is continued without brea&s or HhoidaysH.
[12]
;any
"eo"e are diagnosed ony after treatment ideay shoud have begun.
[12]
'he desired outcome of
treatment is a ong term "asma HIV%IJ( count beow 28 co"ies/mC.
[12]
Ceves to determine if
treatment is effective are initiay recommended after four wee&s and once eves fa beow
28 co"ies/mC chec&s every three to si# months are ty"icay ade@uate.
[12]
Inade@uate contro is
deemed to be greater than 088 co"ies/mC.
[12]
>ased on these criteria treatment is effective in more
than /2= of "eo"e during the first year.
[12]
>enefits of treatment incude a decreased ris& of "rogression to (ID* and a decreased ris& of death.
[1))]
In the deveo"ing word treatment aso im"roves "hysica and menta heath.
[1)+]
.ith treatment
there is a 98= reduced ris& of ac@uiring tubercuosis.
[119]
(dditiona benefits incude a decreased ris&
of transmission of the disease to se#ua "artners and a decrease in mother%to%chid transmission.
[119]
'he effectiveness of treatment de"ends to a arge "art on com"iance.
[12]
Ieasons for non%
adherence incude "oor access to medica care!
[1)0]
inade@uate socia su""orts! menta
iness and drug abuse.
[1)2]
'he com"e#ity of treatment regimens (due to "i numbers and dosing
fre@uency) and adverse effects may reduce adherence.
[1)7]
?ven though cost is an im"ortant issue
with some medications!
[1)9]
09= of those who needed them were ta&ing them in ow and midde
income countries as of )818
[117]
and the rate of adherence is simiar in ow%income and high%income
countries.
[1)5]
*"ecific adverse events are reated to the antiretrovira agent ta&en.
[1)/]
*ome reativey common
adverse events incudeG i"odystro"hy syndrome! dysi"idemia! anddiabetes meitus! es"eciay with
"rotease inhibitors.
[18]
Dther common sym"toms incude diarrhea!
[1)/][1+8]
and an increased ris&
of cardiovascuar disease.
[1+1]
Jewer recommended treatments are associated with fewer adverse
effects.
[12]
4ertain medications may be associated with birth defects and therefore may be unsuitabe
for women ho"ing to have chidren.
[12]
'reatment recommendations for chidren are sighty different from those for aduts. In the deveo"ing
word! as of )818! )+= of chidren who were in need of treatment had access.
[1+)]
>oth the .ord
Heath Drgani$ation and the 3nited *tates recommend treatment for a chidren ess than tweve
months of age.
[1++][1+0]
'he 3nited *tates recommends in those between one year and five years of
age treatment in those with HIV IJ( counts of greater than 188!888 co"ies/mC! and in those more
than five years treatments when 4D0 counts are ess than 288/B.
[1++]
#""ortunistic infections
;easures to "revent o""ortunistic infections are effective in many "eo"e with HIV/(ID*. In addition
to im"roving current disease! treatment with antiretroviras reduces the ris& of deveo"ing additiona
o""ortunistic infections.
[1)/]
Vaccination against he"atitis ( and > is advised for a "eo"e at ris& of
HIV before they become infected- however it may aso be given after infection.
[1+2]
'rimetho"rim/sufametho#a$oe "ro"hya#is between four and si# wee&s of age and ceasing
breastfeeding in infants born to HIV "ositive mothers is recommended in resource imited settings.
[1+)]
It is aso recommended to "revent ,4, when a "ersonEs 4D0 count is beow )88 ces/uC and in
those who have or have "reviousy had ,4,.
[1+7]
,eo"e with substantia immunosu""ression are
aso advised to receive "ro"hyactic thera"y for to#o"asmosis and 4ry"tococcus meningitis.
[1+9]
(""ro"riate "reventive measures have reduced the rate of these infections by 28= between
1//) and 1//9.
[1+5]
Alternative medicine
In the 3*! a""ro#imatey 78= of "eo"e with HIV use various forms of com"ementary or aternative
medicine!
[1+/]
even though the effectiveness of most of these thera"ies has not been estabished.
[108]
.ith res"ect to dietary advice and (ID* some evidence has shown a benefit
from micronutrient su""ements.
[101]
?vidence for su""ementation with seenium is mi#ed with some
tentative evidence of benefit.
[10)]
'here is some evidence that vitamin ( su""ementation in chidren
reduces mortaity and im"roves growth.
[101]
In (frica in nutritionay com"romised "regnant and
actating women a mutivitamin su""ementation has im"roved outcomes for both mothers and
chidren.
[101]
Dietary inta&e of micronutrients at ID( eves by HIV%infected aduts is recommended by
the .ord Heath Drgani$ation.
[10+][100]
'he .HD further states that severa studies indicate that
su""ementation of vitamin (! $inc! and iron can "roduce adverse effects in HIV "ositive aduts.
[100]
'here is not enough evidence to su""ort the use of herba medicines.
[102]
Prognosis
Disabiity%ad:usted ife year for HIV and (ID* "er 188!888 inhabitants as of )880.
no data
10
1025
2550
50100
100500
5001000
10002500
25005000
50007500
7500-10000
10000-50000
50000
HIV/(ID* has become a chronic rather than an acutey fata disease in many areas of the word.
[107]
,rognosis varies between "eo"e! and both the 4D0 count and vira oad are usefu for "redicted
outcomes.
[10]
.ithout treatment! average surviva time after infection with HIV is estimated to be / to
11 years! de"ending on the HIV subty"e.
[0]
(fter the diagnosis of (ID*! if treatment is not avaiabe!
surviva ranges between 7 and 1/ months.
[109][105]
H((I' and a""ro"riate "revention of o""ortunistic
infections reduces the death rate by 58=! and raises the ife e#"ectancy for a newy diagnosed
young adut to )8<28 years.
[107][10/][128]
'his is between two thirds
[10/]
and neary that of the genera
"o"uation.
[12][121]
If treatment is started ate in the infection! "rognosis is not as goodG
[12]
for e#am"e!
if treatment is begun foowing the diagnosis of (ID*! ife e#"ectancy is O18<08 years.
[12][107]
Haf of
infants born with HIV die before two years of age without treatment.
[1+)]
'he "rimary causes of death from HIV/(ID* are o""ortunistic infections and cancer! both of which
are fre@uenty the resut of the "rogressive faiure of the immune system.
[1+5][12)]
Iis& of cancer
a""ears to increase once the 4D0 count is beow 288/PC.
[12]
'he rate of cinica disease "rogression
varies widey between individuas and has been shown to be affected by a number of factors such as
a "ersonEs susce"tibiity and immune function-
[12+]
their access to heath care! the "resence of co%
infections-
[109][120]
and the "articuar strain (or strains) of the virus invoved.
[122][127]
'ubercuosis co%infection is one of the eading causes of sic&ness and death in those with HIV/(ID*
being "resent in a third of a HIV infected "eo"e and causing )2= of HIV reated deaths.
[129]
HIV is
aso one of the most im"ortant ris& factors for tubercuosis.
[125]
He"atitis 4 is another very common
co%infection where each disease increases the "rogression of the other.
[12/]
'he two most common
cancers associated with HIV/(ID* areFa"osiEs sarcoma and (ID*%reated non%Hodg&inEs ym"homa.
[12)]
?ven with anti%retrovira treatment! over the ong term HIV%infected "eo"e may
e#"erience neurocognitive disorders!
[178]
osteo"orosis!
[171]
neuro"athy!
[17)]
cancers!
[17+][170]
ne"hro"athy!
[172]
and cardiovascuar disease.
[1+8]
It is not cear whether these conditions resut from the HIV
infection itsef or are adverse effects of treatment.
Epidemiology
Main article: Epidemiology of HIV/AIDS
?stimated "revaence in = of HIV among young aduts (12<0/) "er country as of )811.
[177]
No data
<0.10
0.100.5
0.51
15
515
1550
HIV/(ID* is a goba "andemic.
[179]
(s of )81)! a""ro#imatey +2.+ miion "eo"e have HIV
wordwide with the number of new infections that year being about ).+ miion.
[175]
'his is down from
+.1 miion new infections in )881.
[175]
Df these a""ro#imatey 17.5 miion are women and +.0 miion
are ess than 12 years od.
[117]
It resuted in about 1.7 miion deaths in )81)! down from a "ea& of
).) miion in )882.
[117][175]
*ub%*aharan (frica is the region most affected. In )818! an estimated 75= ())./ miion) of a HIV
cases and 77= of a deaths (1.) miion) occurred in this region.
[17/]
'his means that about 2= of the
adut "o"uation is infected
[198]
and it is beieved to be the cause of 18= of a deaths in chidren.
[191]
Here in contrast to other regions women com"ose neary 78= of cases.
[17/]
*outh (frica has the
argest "o"uation of "eo"e with HIV of any country in the word at 2./ miion.
[17/]
Cife
e#"ectancy has faen in the worst%affected countries due to HIV/(ID*- for e#am"e! in )887 it was
estimated that it had dro""ed from 72 to +2 years in >otswana.
[5]
;other%to%chid transmission! as of
)81+! in >otswana and *outh (frica has decreased to ess than 2= with im"rovement in many other
(frican nations due to im"roved access to antiretrovira thera"y.
[19)]
*outh Q *outh ?ast (sia is the second most affected- in )818 this region contained an estimated
0 miion cases or 1)= of a "eo"e iving with HIV resuting in a""ro#imatey )28!888 deaths.
[198]
(""ro#imatey ).0 miion of these cases are in India.
[17/]
In )885 in the 3nited *tates a""ro#imatey 1.) miion "eo"e were iving with HIV! resuting in about
19!288 deaths. 'he 3* 4enters for Disease 4ontro and ,revention estimated that in )885 )8= of
infected (mericans were unaware of their infection.
[19+]
In the 3nited Fingdom as of )88/ there
where a""ro#imatey 57!288 cases which resuted in 217 deaths.
[190]
In 4anada as of )885 there
were about 72!888 cases causing 2+ deaths.
[192]
>etween the first recognition of (ID* in 1/51 and
)88/ it has ed to neary +8 miion deaths.
[197]
,revaence is owest in ;idde ?ast and Jorth (frica at
8.1= or ess! ?ast (sia at 8.1= and .estern and 4entra ?uro"e at 8.)=.
[198]
'he worst affected
?uro"ean countries in )88/ are ?stonia! 3&raine! Iussia! Catvia and ,ortuga.
[199]
History
Main article: History of HIV/AIDS
Discovery
'he Morbidity and Mortality Weely !eport re"orted in 1/51 on what was ater to be caed H(ID*H.
(ID* was first cinicay observed in 1/51 in the 3nited *tates.
[)+]
'he initia cases were a custer of
in:ecting drug users and homose#ua men with no &nown cause of im"aired immunity who showed
sym"toms of Pne"mocystis carinii "neumonia (,4,)! a rare o""ortunistic infection that was &nown
to occur in "eo"e with very com"romised immune systems.
[195]
*oon thereafter! an une#"ected
number of gay men deveo"ed a "reviousy rare s&in cancer caed Fa"osiEs sarcoma(F*).
[19/]
[158]
;any more cases of ,4, and F* emerged! aerting 3.*. 4enters for Disease 4ontro and
,revention (4D4) and a 4D4 tas& force was formed to monitor the outbrea&.
[151]
In the eary days! the 4D4 did not have an officia name for the disease! often referring to it by way
of the diseases that were associated with it! for e#am"e! ym"hadeno"athy! the disease after which
the discoverers of HIV originay named the virus.
[15)][15+]
'hey aso used #aposi$s Sarcoma and
%pport"nistic Infections! the name by which a tas& force had been set u" in 1/51.
[150]
(t one "oint!
the 4D4 coined the "hrase Hthe 0H diseaseH! since the syndrome seemed to affect Haitians!
homose#uas! hemo"hiiacs! and heroin users.
[152]
In the genera "ress! the term H1IIDH! which stood
for gay%reated immune deficiency! had been coined.
[157]
However! after determining that (ID* was
not isoated to the gay community!
[150]
it was reai$ed that the term 1IID was miseading and the
term (ID* was introduced at a meeting in Ruy 1/5).
[159]
>y *e"tember 1/5) the 4D4 started
referring to the disease as (ID*.
[155]
In 1/5+! two se"arate research grou"s ed by Iobert 1ao and Cuc ;ontagnier inde"endenty
decared that a nove retrovirus may have been infecting "eo"e with (ID*! and "ubished their
findings in the same issue of the :ournaScience.
[15/][1/8]
1ao caimed that a virus his grou" had
isoated from a "erson with (ID* was stri&ingy simiar in sha"e to other human '%ym"hotro"ic
viruses (H'CVs) his grou" had been the first to isoate. 1aoEs grou" caed their newy isoated virus
H'CV%III. (t the same time! ;ontagnierEs grou" isoated a virus from a "erson "resenting with
sweing of the ym"h nodes of the nec& and "hysica wea&ness! two characteristic sym"toms of
(ID*. 4ontradicting the re"ort from 1aoEs grou"! ;ontagnier and his coeagues showed that core
"roteins of this virus were immunoogicay different from those of H'CV%I. ;ontagnierEs grou"
named their isoated virus ym"hadeno"athy%associated virus (C(V).
[151]
(s these two viruses turned
out to be the same! in 1/57! C(V and H'CV%III were renamed HIV.
[1/1]
#rigins
Ceft to rightG the (frican green mon&ey source of*IV! the sooty mangabey source of HIV%) and
thechim"an$ee source of HIV%1
>oth HIV%1 and HIV%) are beieved to have originated in non%human "rimates in .est%centra (frica
and weretransferred to humans in the eary )8th century.
[2]
HIV%1 a""ears to have originated in
southern 4ameroonthrough the evoution of *IV(c"$)! a simian immunodeficiency virus (*IV) that
infects wid chim"an$ees (HIV%1 descends from the *IVc"$ endemic in the chim"an$ee
subs"ecies Pan troglodytes troglodytes).
[1/)][1/+]
'he cosest reative of HIV%) is *IV(smm)! a virus of
the sooty mangabey (&ercoceb"s atys atys)! an Dd .ord mon&ey iving in coasta .est (frica
(from southern *enega to western 4Ste dEIvoire).
[77]
Jew .ord mon&eyssuch as the ow
mon&ey are resistant to HIV%1 infection! "ossiby because of a genomic fusion of two vira resistance
genes.
[1/0]
HIV%1 is thought to have :um"ed the s"ecies barrier on at east three se"arate occasions!
giving rise to the three grou"s of the virus! ;! J! and D.
[1/2]
'here is evidence that humans who "artici"ate in bushmeat activities! either as hunters or as
bushmeat vendors! commony ac@uire *IV.
[1/7]
However! *IV is a wea& virus which is ty"icay
su""ressed by the human immune system within wee&s of infection. It is thought that severa
transmissions of the virus from individua to individua in @uic& succession are necessary to aow it
enough time to mutate into HIV.
[1/9]
Murthermore! due to its reativey ow "erson%to%"erson
transmission rate! *IV can ony s"read throughout the "o"uation in the "resence of one or more
high%ris& transmission channes! which are thought to have been absent in (frica before the )8th
century.
*"ecific "ro"osed high%ris& transmission channes! aowing the virus to ada"t to humans and s"read
throughout the society! de"end on the "ro"osed timing of the anima%to%human crossing. 1enetic
studies of the virus suggest that the most recent common ancestor of the HIV%1 ; grou" dates bac&
to circa 1/18.
[1/5]
,ro"onents of this dating in& the HIV e"idemic with the emergence
of cooniaism and growth of arge coonia (frican cities! eading to socia changes! incuding a
higher degree of se#ua "romiscuity! the s"read of "rostitution! and the accom"anying high
fre@uency of genita ucer diseases (such as sy"hiis) in nascent coonia cities.
[1//]
.hie
transmission rates of HIV during vagina intercourse are ow under reguar circumstances! they are
increased many fod if one of the "artners suffers from a se#uay transmitted infection causing
genita ucers. ?ary 1/88s coonia cities were notabe due to their high "revaence of "rostitution
and genita ucers! to the degree that! as of 1/)5! as many as 02= of femae residents of
eastern Finshasa were thought to have been "rostitutes! and! as of 1/++! around 12= of a
residents of the same city had sy"hiis.
[1//]
(n aternative view hods that unsafe medica "ractices in (frica after .ord .ar II! such as unsterie
reuse of singe use syringes during mass vaccination! antibiotic and anti%maaria treatment
cam"aigns! were the initia vector that aowed the virus to ada"t to humans and s"read.
[1/9][)88][)81]
'he eariest we documented case of HIV in a human dates bac& to 1/2/ in the 4ongo.
[)8)]
'he virus
may have been "resent in the 3nited *tates as eary as 1/77!
[)8+]
but the vast ma:ority of infections
occurring outside sub%*aharan (frica (incuding the 3.*.) can be traced bac& to a singe un&nown
individua who became infected with HIV in Haiti and then brought the infection to the 3nited *tates
some time around 1/7/.
[)80]
'he e"idemic then ra"idy s"read among high%ris& grou"s (initiay!
se#uay "romiscuous men who have se# with men). >y 1/95! the "revaence of HIV%1 among gay
mae residents of Jew Tor& and *an Mrancisco was estimated at 2=! suggesting that severa
thousand individuas in the country had been infected.
[)80]
Society and culture
Stigma
Iyan .hite became a"oster chid for HIV after being e#"eed from schoo because he was infected.
Main article: Discrimination against people 'it( HIV/AIDS
(ID* stigma e#ists around the word in a variety of ways! incuding ostracism! re:ection!
discrimination and avoidance of HIV infected "eo"e- com"usory HIV testing without "rior consent or
"rotection of confidentiaity- vioence against HIV infected individuas or "eo"e who are "erceived to
be infected with HIV- and the @uarantine of HIV infected individuas.
[)82]
*tigma%reated vioence or
the fear of vioence "revents many "eo"e from see&ing HIV testing! returning for their resuts! or
securing treatment! "ossiby turning what coud be a manageabe chronic iness into a death
sentence and "er"etuating the s"read of HIV.
[)87]
(ID* stigma has been further divided into the foowing three categoriesG
Instr"mental AIDS stigma6a refection of the fear and a""rehension that are i&ey to be
associated with any deady and transmissibe iness.
[)89]
Symbolic AIDS stigma6the use of HIV/(ID* to e#"ress attitudes toward the socia grou"s or
ifestyes "erceived to be associated with the disease.
[)89]
&o"rtesy AIDS stigma6stigmati$ation of "eo"e connected to the issue of HIV/(ID* or HIV%
"ositive "eo"e.
[)85]
Dften! (ID* stigma is e#"ressed in con:unction with one or more other stigmas! "articuary those
associated with homose#uaity!bise#uaity! "romiscuity! "rostitution! and intravenous drug use.
[)8/]
In many deveo"ed countries! there is an association between (ID* and homose#uaity or
bise#uaity! and this association is correated with higher eves of se#ua "re:udice! such as anti%
homose#ua/bise#ua attitudes.
[)18]
'here is aso a "erceived association between (ID* and a mae%
mae se#ua behavior! incuding se# between uninfected men.
[)89]
However! the dominant mode of
s"read wordwide for HIV remains heterose#ua transmission.
[)11]
In )88+! as "art of an overa reform of marriage and "o"uation egisation! it became ega for
"eo"e with (ID* to marry in 4hina.
[)1)]
$conomic im"act
Main articles: Economic impact of HIV/AIDS and &ost of HIV treatment
4hanges in ife e#"ectancy in some (frican countries
HIV/(ID* affects the economics of both individuas and countries.
[191]
'he gross domestic "roduct of
the most affected countries has decreased due to the ac& of human ca"ita.
[191][)1+]
.ithout "ro"er
nutrition! heath care and medicine! arge numbers of "eo"e die from (ID*%reated com"ications.
'hey wi not ony be unabe to wor&! but wi aso re@uire significant medica care. It is estimated that
as of )889 there were 1) miion (ID* or"hans.
[191]
;any are cared for by edery grand"arents.
[)10]
>y affecting mainy young aduts! (ID* reduces the ta#abe "o"uation! in turn reducing the
resources avaiabe for "ubic e#"enditures such as education and heath services not reated to
(ID* resuting in increasing "ressure for the stateEs finances and sower growth of the economy.
'his causes a sower growth of the ta# base! an effect that is reinforced if there are growing
e#"enditures on treating the sic&! training (to re"ace sic& wor&ers)! sic& "ay and caring for (ID*
or"hans. 'his is es"eciay true if the shar" increase in adut mortaity shifts the res"onsibiity and
bame from the famiy to the government in caring for these or"hans.
[)10]
(t the househod eve! (ID* causes both oss of income and increased s"ending on heathcare. (
study in4Ste dEIvoire showed that househods having a "erson with HIV/(ID*! s"ent twice as much
on medica e#"enses as other househods. 'his additiona e#"enditure aso eaves ess income to
s"end on education and other "ersona or famiy investment.
[)12]
%eligion and AIDS
Main article: !eligion and HIV/AIDS
'he to"ic of reigion and (ID* has become highy controversia in the "ast twenty years! "rimariy
because some reigious authorities have "ubicy decared their o""osition to the use of condoms.
[)17]
[)19]
'he reigious a""roach to "revent the s"read of (ID* according to a re"ort by (merican heath
e#"ert ;atthew Haney tited )(e &at(olic &("rc( and t(e *lobal AIDS &risis argues that cutura
changes are needed incuding a re%em"hasis on fideity within marriage and se#ua abstinence
outside of it.
[)19]
*ome reigious organisations have caimed that "rayer can cure HIV/(ID*. In )811! the >>4
re"orted that some churches in Condon were caiming that "rayer woud cure (ID*! and
the Hac&ney%based 4entre for the *tudy of *e#ua Heath and HIV re"orted that severa "eo"e
sto""ed ta&ing their medication! sometimes on the direct advice of their "astor! eading to a number
of deaths.
[)15]
'he *ynagogue 4hurch Df ( Jations advertise an Hanointing waterH to "romote 1odEs
heaing! athough the grou" deny advising "eo"e to sto" ta&ing medication.
[)15]
Media "ortrayal
Main article: Media portrayal of HIV/AIDS
Dne of the first high%"rofie cases of (ID* was the (merican Ioc& Hudson! a gay actor who had
been married and divorced earier in ife! who died on ) Dctober 1/52 having announced that he was
suffering from the virus on )2 Ruy that year. He had been diagnosed during 1/50.
[)1/]
( notabe
>ritish casuaty of (ID* that year was Jichoas ?den! a gay "oitician and son of the ate "rime
minister (nthony ?den.
[))8]
Dn Jovember )0! 1//1! the virus caimed the ife of >ritish roc&
starMreddie ;ercury! ead singer of the band Uueen! who died from an (ID* reated iness having
ony reveaed the diagnosis on the "revious day.
[))1]
However he had been diagnosed as HIV
"ositive during 1/59.
[)))]
Dne of the first high%"rofie heterose#ua cases of the virus was (rthur (she!
the (merican tennis "ayer. He was diagnosed as HIV "ositive on +1 (ugust 1/55! having
contracted the virus from bood transfusions during heart surgery earier in the 1/58s. Murther tests
within )0 hours of the initia diagnosis reveaed that (she had (ID*! but he did not te the "ubic
about his diagnosis unti ("ri 1//).
[))+]
He died! aged 0/! as a resut on 7 Mebruary 1//+.
[))0]
'herese MrareEs "hotogra"h of gay activist David Firby! as he ay dying from (ID* whie surrounded
by famiy! was ta&en in ("ri 1//8. +I,E maga-ine said the "hoto became the one image Hmost
"owerfuy identified with the HIV/(ID* e"idemic.H 'he "hoto was dis"ayed in +I,E maga-ine! was
the winner of the .ord ,ress ,hoto! and ac@uired wordwide notoriety after being used in a 3nited
4oors of >enetton advertising cam"aign in 1//).
[))2]
In 1//7! Rohnson ($iga a 3gandan%born
4anadian was diagnosed with HIV! but subse@uenty had un"rotected se# with 11 women without
discosing his diagnosis. >y )88+ seven had contracted HIV! and two died from com"ications
reated to (ID*.
[))7][))9]
($iga was convicted of first%degree murder and is iabe to a ife sentence.
[))5]
Denial& cons"iracies
Main articles: AIDS denialism and Discredited HIV/AIDS origins t(eories
( sma grou" of individuas continue to dis"ute the connection between HIV and (ID*!
[))/]
the
e#istence of HIV itsef! or the vaidity of HIV testing and treatment methods.
[)+8][)+1]
'hese caims!
&nown as (ID* deniaism! have been e#amined and re:ected by the scientific community.
[)+)]
However! they have had a significant "oitica im"act! "articuary in *outh (frica! where the
governmentEs officia embrace of (ID* deniaism (1///<)882) was res"onsibe for its ineffective
res"onse to that countryEs (ID* e"idemic! and has been bamed for hundreds of thousands of
avoidabe deaths and HIV infections.
[)++][)+0][)+2]
*evera discredited cons"iracy theories have hed that HIV was created by scientists! either
inadvertenty or deiberatey. D"eration IJM?F'IDJ was a wordwide *oviet active
measures o"eration to s"read the caim that the 3nited *tates had created HIV/(ID*. *urveys show
that a significant number of "eo"e beieved < and continue to beieve < in such caims.
[)+7]
Misconce"tions
Main article: Misconceptions abo"t HIV/AIDS
'here are many misconce"tions about HIV and (ID*. 'hree of the most common are that (ID* can
s"read through casua contact! that se#ua intercourse with a virgin wi cure (ID*!
[)+9][)+5][)+/]
and that
HIV can infect ony homose#ua men and drug users. Dther misconce"tions are that any act of ana
intercourse between two uninfected gay men can ead to HIV infection! and that o"en discussion of
homose#uaity and HIV in schoos wi ead to increased rates of homose#uaity and (ID*.
[)08][)01]
Research
Main article: HIV/AIDS researc(
HIV/(ID* research incudes a medica research which attem"ts to "revent! treat! or cure HIV/(ID*
aong with fundamenta research about the nature of HIV as an infectious agent and (ID* as the
disease caused by HIV.
;any governments and research institutions "artici"ate in HIV/(ID* research. 'his research
incudes behaviora heath interventions such as se# education! anddrug deveo"ment! such as
research into microbicides for se#uay transmitted diseases! HIV vaccines! and antiretrovira drugs.
Dther medica research areas incude the to"ics of "re%e#"osure "ro"hya#is! "ost%e#"osure
"ro"hya#is! and circumcision and HIV.