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HIV Infection

Human Immunodeficiency Virus Infection

Human immunodeficiency virus (HIV) infection is caused by retroviruses HIV-1 and HIV-2, which induce the progressive destruction of CD4+ T cells. The disease follows a progressive course and culminates in life-threatening acquired immunodeficiency syndrome (AIDS).

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Presentation

According to the classification system used by the World Health Organization, there are four hierarchical clinical stages of HIV infections, ranging from stage 1 (asymptomatic) to stage 4 (AIDS). Patients showing at least one symptom attributed to a higher stage are assigned this higher stage. Also, they cannot be re-assigned a lower stage if symptoms are relieved by adequate treatment. This classification is to be understood as a one-way street and includes the following stages [1] [2]:

  • Stage 1. Patients are asymptomatic or may have persistent generalized lymphadenopathy. They may remain in this stage for many years.
  • Stage 2. This stage is also referred to as the mildly symptomatic stage. Patients tend to lose weight, although weight loss doesn't exceed 10% of their body weight. They may present with recurrent infections of the respiratory tract, including otitis media, tonsillitis, sinusitis, pharyngitis, and bronchitis. Dermatological conditions such as herpes zoster flares, papular eruptions on the skin, seborrheic dermatitis, and fungal infections of the nails may be reported. Angular cheilitis may occur repeatedly and may be accompanied by oral ulcerations.
  • Stage 3. During this moderately symptomatic stage, HIV patients contract more severe infections. Systemic bacterial infections may affect the respiratory tract, the gastrointestinal and urogenital systems, muscles, joints, and bones, and possibly the central nervous system. They result in fever and diarrhea persisting for more than a month, and weight loss, which now exceeds 10% of the patient's body weight. The concurrent and recurrent development of mucocutaneous conditions such as oral candidiasis, hairy leukoplakia, acute necrotizing ulcerative stomatitis, gingivitis, and periodontitis may suggest an immune disorder and increasingly reduce the patient's quality of life. Laboratory analyses of blood samples may reveal anemia, leukopenia, and/or thrombocytopenia.
  • Stage 4. Progression to this stage is associated with the development of AIDS. It may be referred to as severely symptomatic stage and includes about two dozen AIDS-defining illnesses, as follows:
    • Candidiasis of the esophagus, bronchi, trachea, or lungs (but not the mouth)
    • Cervical cancer, invasive
    • Coccidiomycosis, disseminated or extrapulmonary
    • Cryptococcosis, extrapulmonary
    • Cryptosporidiosis, chronic intestinal (lasting more than one month)
    • Cytomegalovirus disease (other than liver, spleen, and nodes)
    • Cytomegalovirus retinitis with loss of vision
    • Encephalopathy, HIV-related
    • Herpes simplex infection, chronic mucocutaneous or bronchitis, pneumonitis, or esophagitis
    • Histoplasmosis, disseminated or extrapulmonary
    • Isosporiasis, chronic intestinal (lasting more than one month)
    • Kaposi sarcoma
    • Lymphoma, Burkitt's
    • Lymphoma, immunoblastic
    • Lymphoma, primary of brain
    • Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary
    • Mycobacterium tuberculosis
    • Mycobacterium, other or unspecified species, disseminated or extrapulmonary
    • Pneumocystis jiroveci pneumonia
    • Pneumonia, recurrent
    • Progressive multifocal leukoencephalopathy
    • Salmonella septicemia, recurrent
    • Toxoplasmosis of brain
    • Wasting syndrome due to HIV

Of note, the clinical stages defined for children infected with HIV differ from those described above [2]. Additional symptoms commonly observed in pediatric patients comprise persistent hepatosplenomegaly, extensive molluscum contagiosum, extensive wart virus infection, and linear gingival erythema during stage 2 of an HIV infection, as well symptomatic lymphoid interstitial pneumonitis and chronic HIV-associated lung disease, including bronchiectasis, during stage 3. Besides the majority of the aforementioned conditions, AIDS-defining illnesses to be observed in children include unexplained severe wasting, stunting, or severe malnutrition that don't respond to standard therapy. Recurrent severe bacterial infections, which are attributed to stage 3 in adult patients, are considered AIDS-defining in children.

In some cases, the aforedescribed classical course of HIV infections may be preceded by symptoms of acute HIV infection [3]. During the first 6 to 12 weeks after primary exposure to the pathogen, the virus aggressively replicates in the lymphoid tissues. This is associated with high viral loads and declining lymphocyte counts. Non-specific, constitutional symptoms may manifest before the beginning of clinical latency. They may be described as flu- or mononucleosis-like symptoms [4].

Generalized Lymphadenopathy
  • Within 1-4 weeks after the initial exposure and contraction of the virus, constitutional symptoms - malaise, fatigue, weight loss, accompanied by fever, joint pain, and generalized lymphadenopathy are primarily observed.[symptoma.com]
  • Persistent Generalized Lymphadenopathy (PGL) There is loss of normal lymph node architecture as the immune system fails with emergence from latency of HIV infection. It is marked by development of generalized lymphadenopathy.[library.med.utah.edu]
  • Generalized lymphadenopathy in homosexual men. Ann Intern Med 1983; 99:585-91. 156. Nokta MA, Li XD, Nichols J, Pou A, Asmuth D, Pollard RB.[hivinsite.ucsf.edu]
  • In some patients, persistent generalized lymphadenopathy is an outward sign of infection. During this time, the viral load, if untreated, tends to persist at a relatively steady state, but the CD4 T-cell count steadily declines.[emedicine.medscape.com]
Sore Throat
  • The initial infection can be mild or very severe and can be accompanied by fever , swollen lymph nodes , joint and muscle aches , and sore throat . Other symptoms can include chills , night sweats , and mouth ulcers .[medicinenet.com]
  • Other common symptoms can include headache, swollen lymph nodes, and sore throat. These symptoms can occur within days or weeks of the initial exposure to the virus during a period called primary or acute HIV infection.[hivinsite.ucsf.edu]
  • Symptoms can include: fever (raised temperature) body rash sore throat swollen glands headache upset stomach joint aches and pains muscle pain. These symptoms can happen because your body is reacting to the HIV virus.[avert.org]
  • These can include: headache fever tiredness swollen lymph nodes sore throat thrush rash muscle and joint pain ulcers in the mouth ulcers on the genitals night sweats diarrhea Early HIV symptoms generally arise within one to two months after transmission[healthline.com]
Pharyngitis
  • […] patients in this stage, whereas infections by varicella zoster virus (VZV, the causative agent of herpes zoster), recurrent oral ulcerations, papular eruptions on the skin, and recurrent infections of the respiratory tract (including sinusitis, otitis, and pharyngitis[symptoma.com]
  • Although some patients with acute HIV-1 infection experience fever, lymphadenopathy, pharyngitis, skin rash, myalgia, arthralgia, and other symptoms, 1-6 a recent prospective study shows that most patients have nonspecific and relatively mild signs and[aidsinfo.nih.gov]
  • Prospective studies of acute HIV infections show that fever, lymphadenopathy, pharyngitis, diffuse erythematous rash, arthralgia/myalgia, diarrhea, and headache are the commonest symptoms seen with acute HIV infection.[library.med.utah.edu]
Fever
  • The patient presented with acute onset of fever, cough, hemoptysis and malaise.[ncbi.nlm.nih.gov]
  • We report the case of a 44-year-old Chinese man with edema, hematuria, and fever who presented at West China Hospital, Sichuan University, Chengdu, Sichuan, China, in 2013.[ncbi.nlm.nih.gov]
  • A 45 year old male with a past medical history of well controlled hypertension presented with fever, dizziness and non-bloody diarrhea.[ncbi.nlm.nih.gov]
  • Symptoms can include: fever (raised temperature) body rash sore throat swollen glands headache upset stomach joint aches and pains muscle pain. These symptoms can happen because your body is reacting to the HIV virus.[avert.org]
  • These symptoms can include: nausea vomiting fatigue fever Symptoms associated with HIV itself, such as cognitive impairment, can also become apparent. HIV is transmittable soon after it’s introduced into the body.[healthline.com]
Weight Loss
  • If there is a further decline in immune function, more serious symptoms and signs can develop, such as dementia and cognitive changes, severe weight loss , wasting syndrome, opportunistic infections, and malignant tumors.[medicinenet.com]
  • Clinical stage 3 - consists of more severe cases with symptoms of unexplained chronic diarrhea and fever lasting for more than one month, as well as severe weight loss.[symptoma.com]
  • Kaposi’s sarcoma is less common in black Africans Pneumocystis Carinii Pneumonia (PCP) Fever for more than a month Persistent diarrhoea for more than a month leading to wasting syndrome Weight loss (more than 10 percent of the usual body weight) Generalised[health24.com]
  • Symptoms can include: weight loss chronic diarrhoea night sweats fever persistent cough mouth and skin problems regular infections serious illness or disease. What is AIDS? It’s important to understand the difference between HIV and AIDS.[avert.org]
Fatigue
  • These symptoms can include recurrent infections, including fungal infection of the mouth ( oral thrush ) or vagina, rashes , fungal infections of the nails , fatigue , diarrhea , vomiting , leukoplakia of the tongue, and weight loss .[medicinenet.com]
  • Those who do have symptoms generally experience symptoms similar to the common cold or flu: fever, fatigue, and, often, rash. Other common symptoms can include headache, swollen lymph nodes, and sore throat.[hivinsite.ucsf.edu]
  • When people are first infected, symptoms of fever, rashes, swollen lymph nodes, and fatigue may last a few days to several weeks. Many infected people remain well for more than a decade.[merckmanuals.com]
Malaise
  • The patient presented with acute onset of fever, cough, hemoptysis and malaise.[ncbi.nlm.nih.gov]
  • Hodinka Abstract A 15-year-old previously healthy male presented with fever, vomiting, diarrhea, malaise, and altered mental status.[pediatrics.aappublications.org]
  • Within 1-4 weeks after the initial exposure and contraction of the virus, constitutional symptoms - malaise, fatigue, weight loss, accompanied by fever, joint pain, and generalized lymphadenopathy are primarily observed.[symptoma.com]
  • Any of the following symptoms can occur: Decreased appetite Fatigue Fever Headache Malaise Muscle stiffness or aching Rash Sore throat Swollen lymph glands Ulcers of the mouth and esophagus These symptoms can last from a few days to 4 weeks, and then[ufhealth.org]
  • Symptoms are fever, weight loss, hepatosplenomegaly, malaise, and abdominal pain. The diagnosis is generally confirmed by recovering the pathogen from a sterile tissue (usually blood).[journalofethics.ama-assn.org]
Sepsis
  • […] addition, persistent oropharyngeal candidiasis, oral hairy leukoplakia, severe necrotizing infections of the oral cavity (including the gums and the teeth), and various bacterial infections of the respiratory, central nervous system, skeletal systems or sepsis[symptoma.com]
  • HIV is the leading cause of death among women of reproductive age, and it contributes significantly to maternal mortality due both to progression of the disease itself and through higher rates of sepsis, anaemia and other pregnancy-related conditions.[unfpa.org]
Diarrhea
  • The Global Enteric Multicenter Study enrolled children with moderate-to-severe diarrhea (MSD) and less-severe diarrhea (LSD) between December 2007 and November 2012.[ncbi.nlm.nih.gov]
  • These symptoms can include recurrent infections, including fungal infection of the mouth ( oral thrush ) or vagina, rashes , fungal infections of the nails , fatigue , diarrhea , vomiting , leukoplakia of the tongue, and weight loss .[medicinenet.com]
  • A 45 year old male with a past medical history of well controlled hypertension presented with fever, dizziness and non-bloody diarrhea.[ncbi.nlm.nih.gov]
  • Hodinka Abstract A 15-year-old previously healthy male presented with fever, vomiting, diarrhea, malaise, and altered mental status.[pediatrics.aappublications.org]
Vomiting
  • These symptoms can include recurrent infections, including fungal infection of the mouth ( oral thrush ) or vagina, rashes , fungal infections of the nails , fatigue , diarrhea , vomiting , leukoplakia of the tongue, and weight loss .[medicinenet.com]
  • Hodinka Abstract A 15-year-old previously healthy male presented with fever, vomiting, diarrhea, malaise, and altered mental status.[pediatrics.aappublications.org]
  • These symptoms can include: nausea vomiting fatigue fever Symptoms associated with HIV itself, such as cognitive impairment, can also become apparent. HIV is transmittable soon after it’s introduced into the body.[healthline.com]
  • The most common side effects seen in the studies of Truvada as PrEP include headache, nausea, vomiting, rash and loss of appetite. In some people, tenofovir can increase creatinine and transaminases.[aidsinfonet.org]
Chronic Diarrhea
  • Some patients may have symptoms that are often seen with HIV but are nonspecific, such as chronic diarrhea or nonspecific skin findings (seborrheic dermatitis, multiple molluscum contagiosum, poorly responsive psoriasis and prurigo nodularis).[accessmedicine.mhmedical.com]
  • Clinical stage 3 - consists of more severe cases with symptoms of unexplained chronic diarrhea and fever lasting for more than one month, as well as severe weight loss.[symptoma.com]
  • The parasite grows in your intestines and bile ducts, leading to severe, chronic diarrhea in people with AIDS. Cancers common to HIV/AIDS Kaposi's sarcoma.[mayoclinic.org]
  • diarrhea, with occasional weight loss from malabsorption More common in patients with advanced HIV disease (i.e., CD4 count 200 per mm 3 [0.20 10 9 per L]) — Diagnosis of exclusion Intestinal malignancies (e.g., non-Hodgkin lymphoma, Kaposi sarcoma,[aafp.org]
  • It is associated with an unexplained loss of 10% or more of normal body weight plus chronic diarrhea (30 days or more) or chronic weakness with fever (30 days or more).[medbroadcast.com]
Oral Ulcers
  • ulcerations, papular eruptions on the skin, and recurrent infections of the respiratory tract (including sinusitis, otitis, and pharyngitis) belong to this category.[symptoma.com]
  • About 30%-60% of people infected with HIV develop flu-like symptoms such as sore throat, headache, mild fever, fatigue, muscle and joint pains, swelling of the lymph nodes, rash, and (occasionally) oral ulcers.[health24.com]
  • Oral ulcer caused by herpes simplex virus in a patient with human immunodeficiency virus infection.[aafp.org]
  • ulcers, leucopenia, thrombocytopenia, and transaminase elevation.[aidsinfo.nih.gov]
Recurrent Oral Ulceration
  • oral ulcerations, papular eruptions on the skin, and recurrent infections of the respiratory tract (including sinusitis, otitis, and pharyngitis) belong to this category.[symptoma.com]
Arthralgia
  • Although some patients with acute HIV-1 infection experience fever, lymphadenopathy, pharyngitis, skin rash, myalgia, arthralgia, and other symptoms, 1-6 a recent prospective study shows that most patients have nonspecific and relatively mild signs and[aidsinfo.nih.gov]
  • Prospective studies of acute HIV infections show that fever, lymphadenopathy, pharyngitis, diffuse erythematous rash, arthralgia/myalgia, diarrhea, and headache are the commonest symptoms seen with acute HIV infection.[library.med.utah.edu]
Night Sweats
  • Other symptoms can include chills , night sweats , and mouth ulcers . The symptoms and signs of the initial HIV infection have also been compared to infectious mononucleosis .[medicinenet.com]
  • Symptoms can include: weight loss chronic diarrhoea night sweats fever persistent cough mouth and skin problems regular infections serious illness or disease. What is AIDS? It’s important to understand the difference between HIV and AIDS.[avert.org]
  • These can include: headache fever tiredness swollen lymph nodes sore throat thrush rash muscle and joint pain ulcers in the mouth ulcers on the genitals night sweats diarrhea Early HIV symptoms generally arise within one to two months after transmission[healthline.com]
Eruptions
  • Cutaneous B-cell lymphoma and cutaneous T-cell lymphoma Skin cancer including melanoma , squamous cell carcinoma , basal cell carcinoma and anal carcinoma Other skin problems Malnutrition Adverse effects of drugs including lipodystrophy (eg, morbilliform eruptions[dermnetnz.org]
  • Molluscum contagiosum is a benign viral papular eruption that frequently affects children and immunocompromised adults.[ncbi.nlm.nih.gov]
  • […] weight), seborrheic dermatitis and fungal infections of the nails are the most prominent features of patients in this stage, whereas infections by varicella zoster virus (VZV, the causative agent of herpes zoster), recurrent oral ulcerations, papular eruptions[symptoma.com]
  • Manifestarile orale includ prezenta de osteoame de 1-10 mm si multipli dinti supranumerari care nu au erupt. Sindromul Muir-Torre este o afectiune autozomal dominanta in care apar neoplasme cutanate sebacee si la nivelul colonului proximal.[romedic.ro]
Encephalopathy
  • We report a case of a new diagnosis of HIV with an extremely high viral load presenting with HIV encephalopathy, in a 54-year-old woman who had been treated with 2 years of extended high-dose immunosuppressant therapy for a recalcitrant pruritic rash[ncbi.nlm.nih.gov]
  • In most severe cases, HIV-related encephalopathy and progressive multifocal leukoencephalopathy (PML), as well as HIV-associated nephropathy and cardiomyopathy develops.[symptoma.com]
  • HIV encephalopathy. Histoplasmosis, disseminated (at a site other than or in addition to the lungs or cervical or hilar lymph nodes). Isosporiasis with diarrhea persisting more than 1 month. Kaposi sarcoma at any age.[journalofethics.ama-assn.org]
  • HIV encephalopathy can result in dementia, especially in adults. Wasting syndrome can sometimes be helped with nutritional counseling and daily high-calorie supplements, but preventing HIV encephalopathy remains very difficult.[kidshealth.org]
Dysmetria
  • A week later he developed ataxia and bilateral cerebellar signs including intention tremors, dysmetria and dysdiadokokinesia.[ncbi.nlm.nih.gov]

Workup

Both direct and indirect assays may be used to confirm HIV infection, and they primarily differ in their window periods [4]:

  • Viral RNA may be detected as early as 1-2 weeks after the infection, with viral loads frequently exceeding 10 million copies per milliliter during acute HIV infection [3].
  • Viral antigen p24 becomes detectable shortly thereafter.
  • The production of antibodies may not be confirmed until >3 weeks after primary exposure.

Currently, diagnosis of HIV infection is performed with fourth generation immunoassays. These are designed to detect HIV antigen p24 as well as IgG and IgM antibodies against HIV-1 and HIV-2, and their specificity and sensitivity are >99.5%. In order to differentiate between HIV-1 and HIV-2, the presence of antibodies directed against one or the other agent needs to be proven. In case of contradictory results, HIV nucleic acids may be amplified and identified using nucleic acid amplification tests [4].

The confirmation of HIV infection entails an extensive laboratory workup to assess the patient's immune status, and to check for co-infections. This workup includes [5]:

  • Quantification of HIV loads
  • HIV genotyping and test for drug-resistance, if feasible
  • Complete blood count and chemistry panel, including CD4+ T-cell counts with percentage
  • Fasting lipid profile
  • Baseline urinalysis and calculated creatinine clearance or estimated glomerular filtration rate
  • Screening for glucose-6-phosphate dehydrogenase deficiency
  • HLA B*5701 screening
  • Test for infections with Mycobacterium tuberculosis, hepatitis B virus, hepatitis C virus, Toxoplasma gondii
  • Test for other sexually transmitted diseases like syphilis and Chlamydia infection

Treatment

Adequate treatment should be provided as soon as HIV infection is diagnosed, irrespective of the presence of symptoms. This applies to both genders and all ages, including pregnant women. Preferred first-line regimens of antiretroviral therapy (ART) are as follows [2]:

  • Adults: tenofovir disoproxil fumarate, lamivudine/emtricitabine, and efavirenz. Alternative regimens replace tenofovir disoproxil fumarate with azidothymidine, or efavirenz with dolutegravir or nevirapine.
  • Pregnant women: tenofovir disoproxil fumarate, lamivudine/emtricitabine, and efavirenz. Alternative regimens replace tenofovir disoproxil fumarate with azidothymidine, or efavirenz with nevirapine.
  • Adolescents: tenofovir disoproxil fumarate, lamivudine/emtricitabine, and efavirenz. Alternative regimens replace tenofovir disoproxil fumarate with azidothymidine or abacavir, or efavirenz with dolutegravir or nevirapine.
  • Children aged <10 years: abacavir, lamivudine, and efavirenz. Alternative regimens replace abacavir with azidothymidine or tenofovir disoproxil fumarate, or efavirenz with nevirapine.
  • Children aged <3 years: abacavir/azidothymidine, lamivudine, and lopinavir plus low-dose ritonavir. In an alternative regimen, lopinavir plus low-dose ritonavir is replaced by nevirapine.

Drug resistance and toxicity are the principal reasons for the choice of alternative regimens, but interactions with any agents employed to treat co-infections and comorbidities should also be considered [2]. In general, fixed-dose combinations and once-daily regimens are preferred to improve adherence to therapeutic recommendations. Lifelong treatment is required, and patients should be monitored for their response to ART. Six and twelve months after the initiation of ART, and annually thereafter, HIV loads should be measured, and CD4+ T-cell counts should be evaluated to assess the patient's immune status. These tests may be complemented by standard analyses of blood samples to detect potential signs of organ failure.

Of note, post-exposure prophylaxis of HIV infection should be provided within 72 hours after the potential acquisition of the virus [2]. In this context, combination regimens comprising tenofovir disoproxil fumarate, lamivudine/emtricitabine, and lopinavir or amprenavir plus low-dose ritonavir are recommended for adolescents and adults.

Prognosis

The use of ART may significantly diminish the risk of progression to AIDS and of premature mortality. On a global scale, the expansion of access to ART has been associated with a 30% decrease in mortality. Increasingly fewer patients develop AIDS-defining illnesses and die of the disease [6]. With regard to survival, it has been estimated that a 25-year old person with HIV and without hepatitis C virus had a mean life expectancy of 64 years, which is about a decade less than the matched general population [7].

Etiology

HIV infection is caused by two related, yet distinct viruses, by HIV-1 and HIV-2. HIV-1 accounts for the majority of infections and severely interferes with T-cell immunity, whereas infections with HIV-2 allow for the establishment of a more effective and sustained immune response against [8].

HIV is mainly transmitted via the sexual route. Furthermore, contact with blood, blood products, and body fluids of HIV patients may lead to an infection. Intravenous drug abuse and needle sharing are the most important risk factors to this end, while the transmission of HIV during the transfusion or transplantation of blood and organs, respectively, has become increasingly rare after the introduction of screenings.

HIV may also be transmitted from the pregnant mother to her unborn child, and from the nursing mother to the infant [9] [10]. The risk of transmission is particularly high in case of incident HIV infections during pregnancy or the postpartum period, and it's precisely these cases that remain undetected in the absence of repeat HIV testing. It may amount to 58%, as has been shown for Rwanda, but is more commonly estimated at about 20% [9]. In general, the risk of transmission may be significantly reduced with ART.

Epidemiology

In 2012, an estimated 35 million people were living with HIV. Both the incidence and prevalence of HIV infections have been declining for about two decades: About 3.7 million people became infected in 1997, approximately 2.3 million new infections occurred in 2012, and an estimated 1.8 million patients contracted the disease in 2016. This development corresponds to an overall reduction by >50%, and it is mainly attributed to the expansion of ART [11].

By far the highest incidence and prevalence rates are reported in Sub-Saharan Africa. In 2012, almost three-fourths of HIV patients worldwide were living in this region. Similarly, the vast majority of children infected with HIV comes from this part of Africa. While mortality related to HIV and AIDS diminished on a global scale, this does not necessarily apply to resource-limited settings as encountered in developing countries [6]. Poverty remains a major barrier to access to education, healthcare, and ART, and large parts of the Sub-Saharan Africa population live below the poverty line [12]. In sum, about 1 million people died of AIDS in 2016 - about 800.000 of them in the African region.

Sex distribution
Age distribution

Pathophysiology

The detrimental consequences of HIV infection are due to the gradual loss of CD4+ T-cells and imbalance in CD4+ T-cell homeostasis, resulting in progressive immunodeficiency and ultimately death. CD4+ T-cells are implicated in cellular and humoral immune responses against infections, and they are selectively infected by HIV. The virus binds to CD4 and enters the target cell. Inside the lymphocyte, the viral genome and enzymes are released and the reverse transcription of viral RNA is initiated. This process is mediated by viral reverse transcriptase and precedes the integration of viral DNA into the host genome by HIV integrase. Transcription factors are required for the subsequent transcription of the viral genome, and the resulting RNA serves as a template for protein biosynthesis at the host's ribosomes. Posttranslational modifications are realized by HIV proteases before virion buds form from viral proteins and RNA. These virion buds undergo a maturation process and are eventually able to infect other cells. They may be released during the lysis of the initial host cell, but they may also reach other cells upon the fusion of infected and uninfected lymphocytes. In any case, the spread of the infection is associated with decreasing quantities of CD4+ T-cells and a reduction in the number of functional cells [8].

Prevention

Because HIV infection is essentially a sexually transmitted disease, information campaigns and sex education are the pillars of prophylaxis. From adolescence onward, boys and girls should be encouraged to practice safer sex. The correct and consistent use of condoms largely reduces the risk of infection, as does the reduction of the number of sexual partners. Before abstaining from condoms, both partners should get tested for HIV.

Distinct measures may dam the spread of the virus at a higher level [2]:

  • In order to comply with the aforementioned recommendation of safer sex, condoms may be provided to those who are unable or unlikely to purchase them.
  • The implementation of needle and syringe programs may save the life of drug addicts.
  • Voluntary medical male circumcision should be offered in high-risk settings and may be associated with an approximately 60% reduction in the risk of female-to-male sexual transmission.
  • Each and every unit of blood, tissues, and organs to be transplanted to another person should be screened for the presence of HIV, among others.

Additionally, people at very high risk of exposure to HIV may be provided pre-exposure prophylaxis containing tenofovir disoproxil fumarate [2]. This may apply to serodiscordant couples, heterosexual men and women, men who have sex with men, transgender people, sex workers, people who inject drugs, and those in prisons and other closed settings.

At the same time, researches worldwide are working intensively on the development of a vaccine against HIV infections [13] [14].

Summary

HIV infection constitutes a pandemia. Incidence and prevalence peaked in the 1990s, but could significantly be reduced by the introduction of highly active antiretroviral therapies. Today, HIV patients who are diagnosed before the progression to advanced-stage disease and provided ART, have a near-to-normal life expectancy [7]. This may give the misleading impression of HIV no longer being a serious threat to health, and it may motivate to neglect safety measures to prevent an infection. Because the vast majority of patients acquires HIV during sexual intercourse, safer sex remains the most important of those prophylactic measures.

Additionally, the global fight against HIV and AIDS is hindered by limited access to medical care and effective treatment in developing countries. Current epidemiological data clearly show a concentration of infections in Sub-Saharan Africa, where people may not be able to afford ART or even HIV testing, so many infections remain undetected and/or untreated. The improvement of accessibility is a major challenge on the way towards the eradication of HIV, as is the continuous education about the prevention of sexually transmitted diseases.

Patient Information

Human immunodeficiency virus (HIV) infection is possibly the most widely known sexually transmitted disease. It follows a progressive course and is associated with a gradual impairment of the immune system, eventually leading to life-threatening acquired immunodeficiency syndrome (AIDS) and death. The development of effective therapies made HIV infections lose some of its dreadfulness, but it currently remains incurable. What's more, HIV infection interferes with the patient's quality of life and constitutes a substantial health and economic burden, so every possible effort should be made to avoid the exposure to the virus:

  • The consistent and correct use of condoms is the most important preventive measure and applies to both genders and all ages.
  • Intravenous drug users should not share needles and syringes, and strive for overcoming their addiction.
  • Medical personnel and everyone else possibly exposed to infected blood, blood products or body fluids should apply appropriate safety measures. In high-risk settings, these may include the prophylactic administration of antiretroviral drugs.

In any case, treatment should be started as early as possible to assure an optimum outcome, so people who have reasons to assume they may have contracted the disease should seek medical assistance and check their HIV status. If antiretroviral treatment is initiated within 72 hours after the initial exposure, HIV infection may possibly be avoided.

References

Article

  1. Weinberg JL, Kovarik CL. The WHO Clinical Staging System for HIV/AIDS. Virtual Mentor. 2010; 12(3):202-206.
  2. WHO Guidelines Approved by the Guidelines Review Committee. In: Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach. 2nd edition. Geneva: World Health Organization; 2016.
  3. Bottone PD, Bartlett AH. Diagnosing Acute HIV Infection. Pediatr Ann. 2017; 46(2):e47-e50.
  4. Guarner J. Human immunodeficiency virus: Diagnostic approach. Semin Diagn Pathol. 2017; 34(4):318-324.
  5. Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2014; 58(1):1-10.
  6. Lima VD, Lourenco L, Yip B, Hogg RS, Phillips P, Montaner JS. AIDS incidence and AIDS-related mortality in British Columbia, Canada, between 1981 and 2013: a retrospective study. Lancet HIV. 2015; 2(3):e92-97.
  7. Lohse N. The road to success. Long-term prognosis for persons living with HIV in Denmark - time trends and risk factors. Dan Med J. 2016; 63(2).
  8. Vidya Vijayan KK, Karthigeyan KP, Tripathi SP, Hanna LE. Pathophysiology of CD4+ T-Cell Depletion in HIV-1 and HIV-2 Infections. Front Immunol. 2017; 8:580.
  9. Drake AL, Wagner A, Richardson B, John-Stewart G. Incident HIV during pregnancy and postpartum and risk of mother-to-child HIV transmission: a systematic review and meta-analysis. PLoS Med. 2014; 11(2):e1001608.
  10. Ogundele MO, Coulter JB. HIV transmission through breastfeeding: problems and prevention. Ann Trop Paediatr. 2003; 23(2):91-106.
  11. Fettig J, Swaminathan M, Murrill CS, Kaplan JE. Global epidemiology of HIV. Infect Dis Clin North Am. 2014; 28(3):323-337.
  12. Haacker M, Birungi C. Poverty as a barrier to antiretroviral therapy access for people living with HIV/AIDS in Kenya. Afr J AIDS Res. 2018; 17(2):145-152.
  13. Gao Y, McKay PF, Mann JFS. Advances in HIV-1 Vaccine Development. Viruses. 2018; 10(4).
  14. Rios A. Fundamental challenges to the development of a preventive HIV vaccine. Curr Opin Virol. 2018; 29:26-32.

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Last updated: 2018-08-01 21:47