MfA - HIV/AIDS

Acquired Immunodeficiency Syndrome – AIDS – is the clinical picture attributed to an infection by the human immunodeficiency virus – HIV.

HIV is a retrovirus, meaning that the virus contains RNA (a major transcription step in human cells to ‘translate’ human DNA into cell proteins) which it uses to ‘rewrite’ the human DNA code within the infected cell, in order for the DNA to produce RNA that suits the virus rather than the human cell. Thus, the infected cell’s DNA will help to produce new HI viruses, rather than produce proteins that are necessary to support life of the individual cell and the entire human’s body. The virus infects major immune system cells, such as the so-called CD4+ T-cells, a subset of T-cells, which are also called ‘helper T-cells’, as well as macrophages, the major immune cells (derived from blood monocytes) within human tissues that phagocyte (engulf and digest) intruding foreign cellular material and bodies, such as some parasites, bacteria or viruses.

By today’s knowledge, there are two types of HI viruses that infect humans, called HIV-1 and HIV-2. HIV-1 is the strain that causes the majority of human infections, is more virulent, and more easily transmitted.

AIDS, caused by HIV, is not one particular disease per se; rather, it is a syndrome, thus a collection of detectable characteristics as the result of specific damages to the overall immune system of the patient. Infection by the HI virus slowly destroys the body’s ability to fight a wide variety of diseases, so-called opportunistic infections – infections that usually only thrive in patients with a severely compromised immune system, such as advanced cancers or lymphomas.

Once the virus has entered the blood stream, it will target the body’s lymphocytes, the white blood cells, whose main job it is, to defend the body from the attack of foreign organisms, such as bacteria, parasites and viruses, and to destroy them. Because the CD4 lymphocytes are a major cell lineage of this defense system, they are the major target of the HI virus. Once the virus has been able to enter the cell, and to insert its own genetic material into the DNA of the lymphocytes, it will use the cell’s reproductive system to make copies of the virus itself. Concurrently, the number of effective CD4+ T-cells in the body, which are able to serve their original purpose, will decrease, causing an ever increasing immune deficiency, and thus, susceptibility of the body to foreign organisms (see above), as well as the survival of mutating/mutated cells, which can ultimately result in the development of tumors and cancers.

The presence of the HI virus does not yet cause any specific clinical disease, although the person can already transmit the virus to others. The ‘acute HIV infection’ slowly progresses via a clinical ‘latent HIV infection’ into an early symptomatic stage and then to ‘AIDS’. Without early antiretroviral therapy, this progression takes an average of nine to ten years, followed by a median survival time after developing full blown AIDS of less than 10 months; however, the rate of progression can vary widely – from less than one month to up to 20 years, depending on one’s individual immune system, general health care, and other health related factors.

The term ‘Acquired Immunodeficiency Syndrome’ – AIDS – first surfaced in 1981, when suddenly previously healthy, young men became afflicted with rare diseases that usually only appeared in terminally ill cancer patients or other severely immunodepressed patients. Especially Pneumocystis carinii pneumonia (PCP – now identified as being caused by Pneumocstis jirovecii), a fairly rare disease of terminally ill cancer patients or other severely immunocompromised patients, suddenly occurred in young men in America and elsewhere. Soon thereafter, other cases of rare diseases surfaced, such as Toxoplasma gondii and Cytomegalovirus infections, often within the brain and subsequently fatal results, pulmonary mold infections caused by diverse Aspergillus geni, Kaposi’s Sarcoma, which used to be a skin cancer in older men in the Mediterranean region, and rare forms of lymphoma, all attacking a new group of people – young healthy adult men – who should have been able to protect themselves by way of their own immune system. Frighteningly for the patients and the medical society alike, these patients wasted away within just a few weeks, regardless of whatever current treatment measures were instigated.

Since all the above listed disease processes have in common, that they are opportunistic infections that usually only flourish in a patient with a severely compromised immune system, the term ‘Acquired Immunodeficiency Syndrome, or AIDS’, was coined to describe this new phenomenon.

Early ‘epidemiological’ studies soon identified homosexual men, and men from Haiti, as the prime group of potential patients/sources of infection. As this misperception remained ‘valid’ for well over one year after the disease began to spread, it unfortunately slowed the recognition and response rate of many governments to recognize that this new disease was more than just an infliction of borderline societal groups. This prejudicial approach by governments worldwide appeared to have contributed, indirectly, to the progress of the disease.

A second stumbling block, delaying effective research in how to fight this new disease, derived from the research community itself. As the causative agent of AIDS was finally identified in France and the USA at nearly the same time, both researchers (Dr. Luc Montagnier and Dr. Robert Gallo, respectively) were fighting for years within the medical society, as well as later in international courts, who was to be crowned as the first discoverer of the virus causing AIDS – human immunodeficiency virus – HIV. This quarrel resulted in the waste of valuable time and efforts on both sides that could have been put to use in a much more efficient way by collaborating in the laboratory than by suing each other in the courts. Thus, it wasn’t until the late 1980s that the first drugs to fight HIV reached the market – at a time when HIV/AIDS had long been declared a pandemic (an epidemic that spreads over a waste geographical region).

HIV-1 is believed to originate from the common chimpanzee, primarily found in southern Cameroon. HIV-2 has been established to originate from the ‘Old World’ monkey (Sooty Mangabey), found in the West African countries of Cameroon, Gabon and Guinea-Bissau. Also, many experts believe that HIV has probably been transferred to humans as a result of direct contact with primates, for instance during hunting or butchery. Another recently published study, states that HIV moved from Africa to the United States via Haiti, and may have entered the US as early as 1969.

Whatever the actual origins of the virus may be, HIV has grown to a pandemic, with an estimated 33.2 million people affected by the disease worldwide as of December 2007. Since its official recognition in 1981, more than 25 million people have died due to HIV/AIDS, thus making it one of the most devastating epidemics in mankind.

Currently, sub-Saharan Africa is the most affected region in the world, accounting for more than one third of the 2.1 million deaths in the year of 2007. The impact on the economic growth potential of those developing countries, and the loss of potential human capital, are enormous.

HIV is transmitted though direct contact of mucous membranes – such as any form of sexual intercourse (vaginal, oral or anal), or by other ways of exchanging bodily fluids, infected with HIV. Obviously, the exchange of, or contamination with infected blood products can be highly infectious, such as blood transfusion, or the accidental contamination with blood tinged (such as hypodermic needles), or other bodily fluid tinged secretions, including sputum, breast milk, semen, vaginal fluid, or even pre-seminal fluid, all of which can contain the HI virus.

The ways of a potential HIV transmission are often exaggerated and incorrect – that is, why it is important to understand the potential risks on how to become a victim of the HIV pandemic and, on how to behave within the presence of known HIV patients without being afraid, and without making the patient even more uncomfortable with his/her situation as necessary.

Sexual transmission – the most obvious, and the most likely way of transmitting the disease. The HI virus can be transmitted during any sexual contacts between two people, whereas 'sexual contact' does not only imply sexual intercourse, it also includes any close bodily contact, such as oral, as well as anal contact and intercourse. Also, spermicide cream (nonoxynol-9) does not prevent the transmission of HIV or other sexually transmitted diseases (STDs), as it only makes the male sperms ‘immobile’, thus can prevent a pregnancy; yet it does not prevent the exchange of bodily fluids during sexual intercourse, and therefore allows any STD to become transmitted, if present. In pregnant women, the virus is also often transmitted from mother to baby during the gestation period, resulting in a ‘congenital HIV infection’.
Blood transfusion – in early cases, prior to the existence of sensitive and specific tests, many patients became the victims of HIV transmitted via an infected blood transfusion during a surgical procedure, or due to the transmission of other blood products, and/or during surgical emergencies that required a blood transfusion.
Transmission through needle sharing – primarily drug addicts who share needles and syringes can easily transmit the HI virus among equals. However, there are many ‘needle exchange’ programs in effect, almost worldwide, without the need for personal identification. Otherwise, the thorough cleansing of the needle and syringe with household bleach (such as Clorox), can provide some limited way of protection (which is neither reliable nor recommended!)
Transmission via a needle stick accident – there have been some rare reports, in which medical personnel contracted HIV through an accidental prick with a needle/syringe after having used it with a HIV-infected patient. Research has put this kind of risk at less than one percent. Obviously, the irresponsible multiple use of needles and/or syringes by any medical personnel, is a potential case for the criminal courts.
Transmission from mother to child – HIV can be transmitted during the gestation period, during delivery, and even during the period of nursing via the mother’s milk. While this kind of transmission is much higher in developing countries than in developed countries, recently, new drugs and drug combinations have resulted in very promising and effective anti-viral treatment schedules. Pre-screening for pregnant women, and the early start of an appropriate treatment has already resulted in some reports where an HIV-positive mother was able to give birth to an HIV-negative baby. Some developing African countries, where the government was sufficiently willing and determined to take every step necessary to reach this goal, have promoted programs to prevent ‘mother-to-child-transmission’ – MTCT – quite effectively (see Prevention).
Occasionally, transmission can occur during organ or tissue (skin) transplants, and, unfortunately, some times due to improperly sterilized or unsterilized dental or medical/surgical equipment.

HIV is not transmitted during ordinary interpersonal contact with someone who is HIV positive or has AIDS – be it shaking hands, using common hand towels, dancing or hugging, and kissing. Even though HIV can be detected in saliva, tears and urine, the chance of becoming infected via those secretions is minimal.

The symptoms of an HIV infection usually only occur at the stage of AIDS – when the virus has weakened the immune system to such an extent that AIDS-related infections, caused by a wide range of bacteria, other viruses, parasites and fungi, overwhelm the body’s defense systems and expand more or less uninhibited. In addition, AIDS also brings along a markedly increased risk of developing certain types of cancer, especially Kaposi’s sarcoma (soft tissue cancer of the blood vessels), cervical cancer (which can progress from the early HPV infection to fully developed cancer within just a few months), and a variety of lymphomas (cancers of white blood cells and the immune system).

Thus, the overall range of symptoms in an AIDS patient can vary greatly, depending on the specific organ(s) and bodily system(s) that are affected first. Typically, some of the general symptoms such as fever and chills, (night) sweats, general weakness, diarrhea and weight loss, as well as swollen glands (lymph nodes) are often found during early physical examinations.

Also, the kinds of opportunistic infections that AIDS patients develop, depend partially on the prevalence of those infections within the patient’s geographic area of residence.

Following, the more frequently occurring diseases are listed according to the affected system:

Pulmonary infections:

Tuberculosis (TB) – (Mycobacterium tuberculosis and M. avium) often occurs in early-stage HIV and can be easily treated; however, within the last decade, multi-drug resistance has developed, especially in HIV patients, making the disease more difficult to treat; can also be transmitted to immunocompetent people via the respiratory tract. While TB usually is a pulmonary disease, it can also occur elsewhere, especially in AIDS patients, and affect the bones, bone marrow, central nervous system (CNS), lymph nodes, liver and the urinary and gastrointestinal tracts.
Cytomegalovirus pneumonia – CMV – the cytomegalovirus belongs to the group of herpes-type viruses, and typically occurs in people who have a suppressed immune system.
Pneumocystis pneumonia – PCP (Pneumocystis pneumonia) – caused by Pneumocystis jirovecii, a yeast-like fungus. The organism was previously called Pneumocystis carinii (and thus Pneumocystis carinii pneumonia – PCP) when it was originally identified in rats. Very rare in immunocompetent people, it is often one of the first indications of AIDS in HIV-untested individuals.
Other fungal infections of the lungs that can occur in AIDS patients include histoplasmosis (Histoplasma capsulatum), cryptococcosis (Cryptococcus neoformans), and candida (Candida albicans and C. galbrata), as well as the rare Aspergillosis (Aspergillus fumigatus), coccidioidomycosis (Coccidioides immitis) and blastomycosis (Blastomyces dermatitidis).

Infections of the gastrointestinal (GI) tract:

Esophagitis and/or gastritis (gastroesophagitis) – inflammation of the lining of the distal esophagus and/or the lining of the stomach. Often caused by fungal, especially candida (candidiasis), or viral (CMV, Herpes simplex-1 virus) infections, bacteria (helicobacter pylori), and rarely also by mycobacteria (tuberculosis). These organisms can also spread to the upper and lower intestinal tract, especially as the immune system weakens.
Bacterial infections of the GI tract usually cause chronic diarrhea, resulting in illnesses such as salmonellosis (Salmonella enteritidis, a gram-negative bacterium, causing typhoid and paratyphoid fever), shigellosis (Shigella dysenteriae, S. flexneri, S. boydii, or S. sonnei, gram-negative, rod-shaped bacteria), listeriosis (Listeria monocytogenes), campylobacteriosis (campylobacter jejuni, a gram-negative spiral microaerophilic bacterium), or Escherichia coli colitis (a gram-negative, facultative anaerobic bacterium which is part of the normal colonic flora, but there are also pathogenic strains, and a suppressed immune system can cause overgrowth).
Fungal GI infections can result from many fungi as described above (see pulmonary infections) as an extra-pulmonary fungal infection. GI involvement with Cryptococcus neoformans is usually a sign of disseminated disease in advanced AIDS.
Parasitic infections can also include the less common cryptosporidiosis (Cryptosporidium parvum, C. hominis, a protozoan [single cell] parasite), microsporidiosis (Microsporidium is a protozoal parasite with 14 subgroups).
Diarrhea per se may also occur as a side effect secondary to the administration of antibiotics for treating any GI or non-GI infections. In the later stages of AIDS, diarrhea may also reflect the increasing inability of the intestinal mucosa to absorb food-derived nutrients appropriately, which will further enhance the so-called HIV-related wasting.

A ‘classic’ HIV-associated viral disease is called ‘progressive multifocal leukoencephalopathy’ (PML) – caused by a type of polyomavirus called the JC virus (JCV), after the initials of the first patient in whom the virus was discovered. PML is a multifocal inflammation of the white matter of the brain, resulting in the gradual destruction of the myelin sheath that covers the axons of nerve cells (demyelinating disease), thus impairing the transmission of nerve impulses. Typical symptoms include weakness and paralysis, gradual vision loss, impaired speech, and progressive cognitive deterioration. The disease progresses rapidly often causing death within just a few months of diagnosis.
Toxoplasmosis (Toxoplasma gondii, a protozoan parasite) usually infects the brain, causing toxoplasma encephalitis, but can also affect the heart, the liver and even the eyes (chorioretinitis).
AIDS dementia complex – ADC – is a common metabolic encephalopathy secondary to HIV activated and infected macrophages and microglia in the brain, which subsequently secrete neurotoxins of both viral and host origin, causing pallor of myelin sheaths, abnormalities of dendritic processes, and neural apoptosis (programmed cell death). Resulting symptoms include cognitive impairment (mental slowness, poor memory and concentration), motor dysfunction (clumsiness due to loss of fine motor control, tremors and poor balance), speech problems, and behavioral changes (apathy, lethargy, reduced emotional responses and spontaneity).
Cryptococcal meningitis, caused by the fungus Cryptococcus neoformans (also see under pulmonary infections), affects the meninges (the thin membrane that covers the brain and the spinal cord) and can cause fatigue, headache, nausea and vomiting, confusion and seizures; left untreated, the disease can lead to the patient’s death.

Kaposi’s sarcoma – a cancer of the lymphatic endothelium forming vascular channels which fill with blood cells, resulting in their characteristic nodular, bruise-like appearance. When first described, it was a rare kind of tumor that occurred in elderly men of the Mediterranean region or Eastern Europe, classically developing on the shins of the lower legs. Since the appearance of HIV, it has become the most frequently occurring HIV/AIDS associated malignancy, presenting itself not only in the skin of the lower limbs, but also on the face, mouth, lips and genitalia. In the mouth, the hard palate is most often affected, followed by the gums. It can also occur anywhere in the GI tract and the pulmonary tract, resulting in diarrhea, malabsorption and intestinal obstruction in the former, and shortness of breath, cough and hemoptysis (coughing of blood) in the latter.
Cervical cancer – caused by different sub-types of human papillomavirus (HPV). The development of cancer in HIV-infected women is defined as the beginning of AIDS. Research studies have shown that cervical cell changes and dysplasia caused by HPV, progress within just a short period of time to cervical cancer which acts much more aggressive and invasive than in non-HIV patients.
Lymphomas – such as high grade B-cell lymphomas, e.g. the Burkitt’s lymphoma (which occurs up to 1,000 times more frequently in HIV than in non-HIV patients), a very aggressive form of the diffuse large B-cell lymphoma (DLBCL), often present in HIV-infected patients, and are at times AIDS-defining. In addition, primary CNS lymphomas occur much more frequently in HIV patients. Many of these lymphomas are caused by the Epstein-Barr virus (the Burkitt’s lymphoma) or the KSHV, and all of them are associated with a poor prognosis for the AIDS patient. In addition, Hodgkin’s disease, a usually low grade type of lymphoma that can be cured by chemotherapy in over 90% of non-HIV patients, can also occur and become more aggressive than usual.
Other malignancies that occur more frequently in AIDS patients than in the average population include anal and rectal cancer in the GI tract, malignant melanoma of the skin or multiple myeloma of the bone marrow.

As the HIV infection turns into full blown AIDS, the general, infection-associated symptoms as listed above, will become more and more serious and pronounced, especially in connection with the development of various opportunistic infections and other AIDS-related diseases. Thus, signs and symptoms of these infections may include some or all of the following:

This section will be limited to describing methods on how to diagnose an HIV infection, rather than elaborating on the diagnostic possibilities of the many opportunistic infections that are associated with HIV/AIDS, as this would greatly exceed the scope of this article.

Most of the opportunistic infections, whether caused by parasites, bacteria, fungi or viruses, can be diagnosed by way of specific cultures, serology, cytology, histopathology or immunohistopathology, and other more sophisticated methods such as ELISA (enzyme-linked immunosorbent assay), PCR (polymerase chain reaction), or other sensitive laboratory techniques, all of which are expensive and often labor intensive. Tumors, benign and malignant, lymphomas and other HIV/AIDS associated malignancies can usually be diagnosed by cytology or by histology from a diagnostic biopsy of the lesion.

In 1993, the US Center for Disease Control (CDC) expanded the diagnosis of AIDS to include all HIV-positive patients whose CD4+T-cell count was registered as below 200/µL of blood, or 14% of all lymphocytes.

The presence of the HI virus can be diagnosed from blood (serum or plasma), sputum or urine samples, by identifying the presence of antibodies to the virus. However, since the development of antibodies takes some time, these tests only turn positive after a lag time of 12 weeks to six months after the initial infection which is called ‘window period’. Previously available tests were primarily the ELISA test, which was repeated when positive, then confirmed by a second test, the so-called Western blot test which identified the presence of HIV proteins. These tests took about two to three weeks to be completed, putting often undue psychological pressure on the patient.

Nowadays, there are a number of so-called Rapid Dry Tests that are very sensitive and can give highly specific information within 2o minutes or less, even distinguishing between HIV-1 and HIV-2 infections. These tests look for antibodies to the virus in blood or other fluids, usually sputum. The oral test is almost as sensitive as the blood test, eliminating the need to draw blood, and thus being ideally suited for less well equipped and staffed health care centers, as is often the case in Africa or other developing countries.

Following the diagnosis of HIV/AIDS, the stage of the disease will be determined, allowing for the prognosis and potential treatment options available for the patient.

The World Health Organization (WHO) introduced a staging system in 1990, which was subsequently updated in 2005 as follows:

This section will concentrate on HIV-related therapy, without detailing the often extensive additional treatment plans that would be required to treat the many possible opportunistic infections that may occur throughout the different HIV stages as listed above.

As of 2005, the average survival time of a patient with the diagnosis of AIDS while taking antiretroviral therapy was estimated to be more than five years. However, this estimate does not consider the positive effect of the discovery of new treatments in the meantime, nor does it take into account the negative effects that may develop due to viral resistance to current drug regimens. Without treatment, AIDS will be fatal within one year, usually due to overwhelming opportunistic infections or malignancies associated with the progressive demise of the host’s own immune system.

HIV is a so-called RNA (ribonucleic acid) virus, meaning that its genetic material is in the form of RNA. Thus, in order for HIV to be able to infect human T-cells, it first needs to convert its RNA into the host’s DNA (deoxyribonucleic acid) – to do this, HIV requires the enzyme called ‘reverse transcriptase’, which is one of the major attack points of antiretroviral therapy.

Currently available antiretroviral (ARV) drugs inhibit the growth and/or the replication of the HI virus at various stages of its life cycle; there are seven classes of drugs for ‘antiretroviral treatment – ART:

Nucleoside analogue reverse transcriptase inhibitors – NARTIs or NRTIs – constitute the first group of antiretroviral drugs that were developed; they inhibit the replication of ‘reverse transcriptase’, the major HIV enzyme. Drugs include abacavir (Ziagen®, Trizivir™ [abacavir, lamivudine and zidovudine], Kivexa®/Epzicom™ [abacavir and lamivudine]), didanosine (Videx® and Videx EC®), lamivudine (Epivir®, Epivir-EBV® and Zeffix®), stavudine (Zerit®), zalcitabine (Hivid®) and zidovudine or azidothymidine {AZT} (Retrovir® and Retrovis®). Another drug, FDA approved in 2003, called emtricitabine (Emtriva®, Truvada® or Atripla®) must be used in combination with at least two other AIDS drugs, but then treats both HIV-1 and hepatitis B.

Major side effects: abacavir – hypersensitivity reactions, such as a rash, fever, nausea, vomiting, diarrhea, abdominal pain; emtricitabine – nausea, vomiting, abdominal pain, breathing difficulties, fatigue; zidovudine – bone marrow suppression (!), causing a decrease of both erythrocytes (red blood cells) and leucocytes (white blood cells). All inhibitors of the enzyme ‘reverse transcriptase’ have a potential possibility of severe, even fatal liver damage.

Non-nucleoside reverse transcriptase inhibitors – NNRTIs – bind directly to the viral enzyme reverse transcriptase, and thus prevent healthy T-cells from becoming infected with HIV. Drugs include delavirdine (Rescriptor®), efavirenz (Sustiva® and Stocrin®), etravirine (TMC-125 or Intelence®) and nevirapine (Viramune®).

Major side effects of all NNRTIs is a rash; possibility of severe, even fatal liver damage.

Nucleotide reverse transcriptase inhibitors – NtRTIs – work similar to the NRTIs, by interfering with the replication of the enzyme ‘reverse transcriptase’, and thus preventing the virus to insert its RNA into the cell’s DNA. However, NtRTIs act faster than NRTIs – tenofovir (Viread® {Truvada® - tenofovir & emtricibanine; Atripla® - fixed-dose triple combination of tenofovir, emtricibanine & efavirenz}) is the only FDA approved drug, available since 2001, and also effective (but not approved) for the treatment of hepatitis B (HBV). Given in combination with other drugs.

Major side effects are nausea, vomiting, diarrhea and possibility of severe, even fatal liver damage.

Protease inhibitors – PIs – interrupt the HIV replication by interfering with an enzyme called HIV protease, which is necessary in order to hydrolyze viral proteins into functional protein products, required for viral assembly and activity. As PIs interfere in this process, the HI virus becomes disorganized and non-infectious. Drugs include amprenavir (Agenerase®), atazanavir (Reyataz®), darunavir (Prezista®), indinavir (Crixivan®), lopinavir (ABT-378; Kaletra® and Aluvia®), nelfinavir (Viracept®), ritonavir (Norvir®), saquinavir (Invirase®, Fortovase®) and tipranavir (Aptivus®).

Major side effects include nausea, diarrhea and other GI problems, increased triglyceride levels, interference with glucose metabolism which can progress to diabetes, interference with fat metabolism; may also cause significant side effects if taken in combination with certain other drugs.

Fusion inhibitors – a new class of drugs, given to patients who developed resistance to one or more of the above listed drug groups. Enfuvirtide (Fuzeon®), a peptide, is the only approved fusion inhibitor, binds to gp41, a surface protein of HIV, thus preventing the virus from attaching to the surface of healthy T-cells and from entering the cell (‘entry inhibitor’). Fuzeon is only used in combination with other drugs and given by injection.

Major side effects include a skin reaction at the site of injection, peripheral neuropathy, insomnia, depression.

Integrase inhibitors – the latest group of antiretroviral drugs. The only FDA approved drug, raltegravir (MK-0518; Isentress®) was approved in October 2007 for treatment experienced patients with multidrug resistant HIV strains. The drug blocks the replication of the HIV enzyme ‘integrase’ which the virus requires to hide its own DNA inside the host cell’s DNA, thus preventing the HIV DNA from meshing with the cell’s DNA. Raltegravir must be used in combination with other antiretroviral drugs.

Major side effects include diarrhea, nausea, headache and fever.

CCR5 antagonists – are another new class of drugs, for use in treatment experienced patients. The first drug, maraviroc (Selyentry®, or Celsentri® [outside the USA]), was approved by the FDA in August 2007. This drug targets a surface protein, called CCR5, which is located on the surface of healthy helper T-cell, and used by HIV as a co-receptor for its entry into the cell. Since HIV can also use CXCR4 as co-receptor for entering a T-cell, a blood test to identify the tropism of the patient’s HIV strain must first be performed, in order to determine the drug’s effectiveness.

Major side effects include liver and cardiovascular problems, upper respiratory tract infections, cough, fever, rash and abdominal pain.

Neither one of the above listed drugs is effective against HIV, if used by itself. Any effective antiretroviral therapy requires the combination of three or more drugs, usually of at least two differently acting groups. Current treatment guidelines focus on achieving the maximum suppression of symptoms for as long as possible. This approach has been termed ‘highly active antiretroviral therapy’ – HAART, whose aim it is to reduce the viral load in a patient to very low to undetectable levels (which does not mean that the virus is gone).

The development of HAART has been highly beneficial to HIV-infected patients, reflected in a substantially increased number of individuals who are now able to live with AIDS. However, HAART does not cure the patient of HIV, and, if treatment is stopped, high levels of HIV-1, often HAART resistant will return. On the other hand, HAART has delayed the progression from HIV infection to AIDS, from a median of nine to ten years without treatment, by four to 12 years. This wide span may be caused by a variety of reasons, such as medication intolerance and side effects, earlier ineffective treatment, infection with a (multi-) drug resistant HIV strain, as well as non-compliance to the often tough treatment schedule by the patient. Reasons for non-adherence or non-persistence with HAART may be found in psychosocial issues, inadequate or poor access to medical care facilities, and the high costs of the regimens, inadequate social support and drug abuse, among other reasons. Furthermore, the complexity of HAART regimens can create non-compliance, as well as the frequent and often very unpleasant side effects that are associated with virtually all drugs.

Many patients have turned to alternative medicine in the quest for help, especially in the early years of HIV/AIDS when no effective drugs were available. While none of those non-traditional ways changed the outcome of HIV/AIDS, in recent years the definition of “alternative therapies” has changed, and refers today more to supportive or ‘complementary’ measurements such as additional herbal and flower remedies to lessen some of the symptoms of the drugs’ side effects, or massage and acupuncture to reduce stress.

Prevention:

Since HIV/AIDS has developed into a pandemic, which at this point in time cannot be cured by any available form of treatment, prevention plays a major role in limiting the spread of the disease as much as possible by avoiding exposure.

Vaccination: As of 2008, there is no vaccine available for HIV. In spite of over 25 years of frantic research efforts by thousands of scientists and the entire pharmaceutical industry, there are no signs of an effective vaccine in sight. Furthermore, the development of a wide range of drugs that inhibit the infection by the virus in a number of different ways, and their ever more stronger potency, already has and will in the future continue to foster the development of mutant HIV strains that will ‘learn’ to circumvent these drugs’ effects. The result of this will be that it will also become ever more difficult to develop one vaccine that will be equally effective to kill present and future variations of the virus.

Blood transfusions and organ and tissue transplants have become almost 100% safe in developed countries, due to extensive and thorough testing procedures prior to providing these products to the patient. As the tests for identifying the virus have become more and more sensitive over the years, this path of transmission has fortunately become negligible. Unfortunately, this is not always true for all developing countries, where the health care system is not sufficiently equipped with the necessary manpower and testing equipment, mostly due to the lack of funds.

Sexual intercourse is still by far the most frequent way of becoming infected with HIV; it is here where prevention measurements are needed most. Thus, as with all sexually transmitted diseases (STDs), preventive measures should be based on avoiding and eliminating sexual contact with an infected person. While the occasionally voiced recommendation of ‘total sexual abstinence’ outside of marriage seems to be rather naïve and unrealistic in view of the human physiology and psychological behavior, the promotion of using condoms appears to be a more realistic approach to this pandemic. Especially, since nowadays there are (latex) condoms available for both men and women, every person can in fact do something to prevent herself/himself to become infected. Fortunately, many governments in developed and developing countries have recognized the need for promoting the use of condoms, and make them available wherever possible. A condom should never be used more than once, because contamination with or leaking of semen occurs frequently upon repeated usage of any kind of condom. Evidence has shown that typical use of condoms can reduce the risk of heterosexually transmitted HIV by about 80% over the long term, although the benefit would most likely be even higher if the condoms are used correctly on every occasion. Furthermore, studies done on couples where one partner is HIV infected have shown that with consistent condom use, the HIV infection rate for the uninfected partner is below 1% per year.
Recent research has also intensified in trying to develop an effective microbicide cream which could provide an additional protective measurement for women, and, especially in connection with condoms, safe millions of lives.

There are two recognized programs, developed by governments and health care organizations, that endorse two ways on how to lower the risk of acquiring HIV/AIDS during sex:
The ABC approach:

The ABC approach was very successfully executed in Uganda, decreasing the HIV prevalence rate from 15% to 5%. Unfortunately, restrictions on giving out free condoms to the population by the government were tied to some development funds for the country, which resulted in a subsequent increase of the HIV prevalence rate.

Personal responsibility – if a person knows that he/she is infected with the HI virus, he/she should accept the responsibility and take every precaution available not to infect another person. This requires, however, that the person knows of his/her status, which means that everyone who may be a potential patient due to his/her life style, should be tested regularly. The latest Rapid Dry tests are easy to perform, quite sensitive and give the result usually within 20 minutes. Many African countries have promoted free testing for their population; however, many people, especially men, are still very reluctant to take the test. Thus, other important efforts for an effective prevention also include:

Community Education Programs – community programs need to be established in order to educate people about the virus, how it can be transmitted and how one can protect oneself from becoming infected. These programs should be given to older children in school as well as to adults at their place of work, at community centers or even in church, especially in developing countries, where the availability of radio and TV programs are limited, or reach only a limited number of people. Part of these courses should also stress the necessity of knowing one’s own status, and knowing the status of one’s sexual partner, prior to engaging in unprotected sex. And to introduce or emphasize the use and need of using a condom – for protecting each other from HIV and other sexually transmittable diseases as well as for preventing an unwanted pregnancy (see above). Voluntary counseling and testing (VCT) should be provided on the spot, and the recommendation of repeating the HIV test, as changing circumstances may call for, should be stressed.

Family Planning – should be given on a community level, similar to the above described program. Expecting mothers should be offered ante-natal care (ANC), including the HIV test as soon as their pregnancy status has been confirmed, in order to start an appropriate antiretroviral therapy, if needed, as soon as possible, and thus allow for the prevention of mother-to-child-transmission (PMTCT). Many such programs in developed as well as in many African and other developing countries have begun to reverse the prevalence of AIDS and MTCT over the last few years, and provided a steady progress in child survival. While the transmission rate from an untreated HIV-positive mother to child during pregnancy, labor and delivery lies at about 25%, this rate drops to around 1%, for children, whose mother received anti-retroviral treatment, and who were delivered via Cesarean section (C-section). Recently, there have also been an increasing number of HIV-negative children born to HIV-positive mothers.
Furthermore, one study by the US National Institute of Health, performed in Kenya and published in 2006, showed that male circumcision that was medically performed can reduce a man’s risk of contracting HIV through heterosexual intercourse by around 50%.

Clean needles – are a major must for both drug addicts and medical personnel. Drug addicts should take advantage of needle exchange programs that are available almost worldwide without questions asked, and never share a needle with any other person, even if this other person is supposedly HIV negative.

Obviously, medical personnel should never consider using needles, syringes or any other potentially infected medical equipment on more than one patient at a time, unless the equipment has been sterilized between patients. Any other behavior would be grossly irresponsible and unjustifiable, regardless of the state of the health care system. The expense of a second needle or syringe is considerably less than the costs – human, socially and economically – of another HIV patient.

Post-exposure prophylaxis – PEP – an antiretroviral treatment should be provided and given to people, immediately following a highly significant exposure. PEP consists of a rather demanding four week schedule of drug dosages, often associated with unpleasant side effects such as diarrhea, nausea and fatigue; however, it also has been shown to provide some good level of preventing an infection, if started early enough and conducted properly.

HIV and AIDS have a clearly negative impact on the economic growth of any country by destroying human capital and increasing financial resources for the care of the patients, especially in developing countries.

Without the availability of an effective general health care system, medicines and proper nutrition, large numbers of people will fall victim to HIV/AIDS in sub-Saharan Africa and elsewhere in developing countries. The loss of (skilled) labor force, associated with a sharp increase of orphans would put a heavy burden on any country, and does so even more desperately in Africa. As the tax income decreases because of a decreasing labor force, the expenses that these governments face in order to treat and take care of a growing number of severely ill patients increases unproportionally, preventing the country from being able to develop its economy and shape its future.

HIV crosses all cultures, national borders and religions – anyone of any age, race, color, sex or sexual orientation can be infected. Only a worldwide, concerted effort can help to fight this pandemic and to hopefully find a long lasting cure in the near future.

_________________________________________________________________________________
DISCLAIMER: The above article is only intended to provide general information regarding this topic. It is not intended and does NOT replace the need to consult a medical or other professional person, if you have or believe to have this disease/disorder. While the article was researched, written and reviewed by medical professionals, and Medicine for Africa, its staff and publisher made every effort to assure accuracy and correctness, it does not claim to be complete, correct or to reflect the very latest stand of medical/scientific knowledge in the disease’s/syndrome’s pathology, diagnostic and/or therapeutic development. Medicine for Africa, its founder, management, staff, writers, reviewers or publishers may NOT be made responsible or legally bound to any information provided above, and cannot be held liable to any conclusions or decisions the reader may draw after reading this article. The reader is explicitly advised to consult a licensed physician and to present his/her specific situation before making any health related decisions.

Medicine for Africa - Medical Information Service