AIDS

Human immunodeficiency virus infection and acquired immunodeficiency

syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with
the human immunodeficiency virus

 HIV (human immunodeficiency virus) is a virus that attacks the body’s

immune system. If HIV is not treated, it can lead to AIDS (acquired
immunodeficiency syndrome).
 There is currently no effective cure. Once people get HIV, they have it for
life.
 But with proper medical care, HIV can be controlled. People with HIV who
get effective HIV treatment can live long, healthy lives and protect their
partners.

Mode of transmission

 HIV is spread primarily by unprotected sex (including anal and vaginal sex)
 contaminated blood transfusions
 hypodermic needles
 from mother to child during pregnancy, delivery, or breastfeeding.
 Most of the affected people have flu-like symptoms within 2 to 4 weeks
after infection. Symptoms may last for a few days or several weeks.
 There is no risk of acquiring HIV if exposed to feces, nasal secretions,
saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated
with blood.
 It is also possible to be co-infected by more than one strain of HIV—a
condition known as HIV superinfection.

3 stages of HIV:

Stage 1 : Acute HIV infection

 People have a large amount of HIV in their blood and are very contagious.
 Many people have flu-like symptoms.
 A part from fever, large tender lymph nodes, throat inflammation, a rash,
headache, tiredness, and/or sores of the mouth and genitals
 The rash, which occurs in 20–50% of cases, presents itself on the trunk and
is maculopapular, classically.
 Some people also develop opportunistic infections at this stage.
  Gastrointestinal symptoms such as such as vomiting or diarrhea may occur
 Neurological symptoms of peripheral neuropathy or Guillain–Barré
syndrome also occur

Stage 2: Chronic HIV infection

 This stage is also called asymptomatic HIV infection or clinical latency.

 this second stage of the natural history of HIV infection can last from about
three years to over 20 years
 typically there are few or no symptoms at first, near the end of this stage
many people experience fever, weight loss, gastrointestinal problems and
muscle pains
 Between 50% and 70% of people also develop persistent generalized
lymphadenopathy, characterized by unexplained, non-painful enlargement of
more than one group of lymph nodes (other than in the groin) for over three
to six months
 HIV is still active and continues to reproduce in the body.
 People may not have any symptoms or get sick during this phase but can
transmit HIV.
 People who take HIV treatment as prescribed may never move into Stage 3
(AIDS).
 Without HIV treatment, this stage may last a decade or longer, or may
progress faster. At the end of this stage, the amount of HIV in the blood
(viral load) goes up and the person may move into Stage 3 (AIDS).

Stage 3: Acquired Immunodeficiency Syndrome

 The most common initial conditions that alert to the presence of AIDS
are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting
syndrome (20%), and esophageal candidiasis. Other common signs include
recurrent respiratory tract infections.
 Opportunistic infections may be caused by bacteria, viruses, fungi,
and parasites that are normally controlled by the immune system. Which
infections occur depends partly on what organisms are common in the
person's environment.These infections may affect nearly every organ
system.
 The most severe stage of HIV infection.
 People with AIDS can have a high viral load and may easily transmit HIV to
others.
 People with AIDS have badly damaged immune systems. They can get an
increasing number of opportunistic infections or other serious illnesses.
 Without HIV treatment, people with AIDS typically survive about three
years.

Pathophysiology

After the virus enters the body, there is a period of rapid viral replication,
leading to an abundance of virus in the peripheral blood.

1.During primary infection, the level of HIV may reach several million virus
particles per milliliter of blood

2.This response is accompanied by a marked drop in the number of

circulating CD4+ T cells.

 The acute viremia is almost invariably associated with activation of CD8+ T

cells, which kill HIV-infected cells, and subsequently with antibody
production, or seroconversion.
 The CD8+ T cell response is thought to be important in controlling virus
levels, which peak and then decline, as the CD4+ T cell counts recover. A
good CD8+ T cell response has been linked to slower disease progression
and a better prognosis, though it does not eliminate the virus
3. Ultimately, HIV causes AIDS by depleting CD4+ T cells.
 This weakens the immune system and allows opportunistic infections. T
cells are essential to the immune response and without them, the body
cannot fight infections or kill cancerous cells. The mechanism of CD4+ T
cell depletion differs in the acute and chronic phases.
 During the acute phase, HIV-induced cell lysis and killing of infected cells
by CD8+ T cells accounts for CD4+ T cell depletion, although apoptosis may
also be a factor.
During the chronic phase, the consequences of generalized immune activation
coupled with the gradual loss of the ability of the immune system to generate
new T cells appear to account for the slow decline in CD4+ T cell numbers.
Although the symptoms of immune deficiency characteristic of AIDS do not
appear for years after a person is infected, the bulk of CD4 + T cell loss occurs
during the first weeks of infection, especially in the intestinal mucosa, which
harbors the majority of the lymphocytes found in the body.
Classification
Two main clinical staging systems are used to classify HIV and HIV-related
disease for surveillance purposes:
1. the WHO disease staging system for HIV infection and disease
2. the CDC classification system for HIV infection.
The CDC's classification system is more frequently adopted in developed
countries. Since the WHO's staging system does not require laboratory tests
The WHO system uses the following categories:

 Primary HIV infection: May be either asymptomatic or associated with acute

retroviral syndrome
 Stage I: HIV infection is asymptomatic with a CD4+ T cell count (also known
as CD4 count) greater than 500 per microlitre (µl or cubic mm) of blood.. May
include generalized lymph node enlargement
 Stage II: Mild symptoms, which may include
minor mucocutaneous manifestations and recurrent upper respiratory tract
infections. A CD4 count of less than 500/µl
 Stage III: Advanced symptoms, which may include
unexplained chronic diarrhea for longer than a month, severe bacterial
infections including tuberculosis of the lung, and a CD4 count of less than
350/µl
 Stage IV or AIDS: severe symptoms, which include toxoplasmosis of the
brain, candidiasis of the esophagus, trachea, bronchi, or lungs, and Kaposi's
sarcoma. A CD4 count of less than 200/µl
The U.S. Centers for Disease Control and Prevention classifies HIV infections
based on CD4 count and clinical symptoms, and describes the infection in five
groups. In those greater than six years of age it is

 Stage 0: the time between a negative or indeterminate HIV test followed less
than 180 days by a positive test.
 Stage 1: CD4 count ≥ 500 cells/µl and no AIDS-defining conditions.
 Stage 2: CD4 count 200 to 500 cells/µl and no AIDS-defining conditions.
 Stage 3: CD4 count ≤ 200 cells/µl or AIDS-defining conditions.
 Unknown: if insufficient information is available to make any of the above
classifications.
For surveillance purposes, the AIDS diagnosis still stands even if, after treatment,
the CD4+ T cell count rises to above 200 per µL of blood or other AIDS-defining
illnesses are cured.

Diagnosis
HIV/AIDS is diagnosed via laboratory testing and then staged based on the
presence of certain signs or symptoms
HIV Testing
Most people infected with HIV develop specific antibodies (i.e. seroconvert)
within three to twelve weeks after the initial infection. Diagnosis of primary HIV
before seroconversion is done by measuring HIV-RNA or p24 antigen. Positive
results obtained by antibody or PCR testing are confirmed either by a different
antibody or by PCR.
Prevention
 Sexual contact :Consistent condom use reduces the risk of HIV transmission
by approximately 80% over the long term.
 Application of a vaginal gel containing tenofovir (a reverse transcriptase
inhibitor) immediately before sex seems to reduce infection rates by
approximately 40% among African women
 Pre-exposure : Antiretroviral treatment among people with HIV whose CD4
count ≤ 550 cells/µL is a very effective way to prevent HIV infection of
their partner
 Post-exposure: A course of antiretrovirals administered within 48 to
72 hours after exposure to HIV-positive blood or genital secretions is
referred to as post-exposure prophylaxis (PEP).[144] The use of the single
agent zidovudine reduces the risk of a HIV infection five-fold following a
needle-stick injury.
 Vaccination: Currently there is no licensed vaccine for HIV or AIDS.[6] The
most effective vaccine trial to date, RV 144, was published in 2009; it found
a partial reduction in the risk of transmission of roughly 30%, stimulating
some hope in the research community of developing a truly effective
vaccine.
 Treatment
 There is currently no cure, nor an effective HIV vaccine. Treatment consists
of highly active antiretroviral therapy (HAART), which slows progression of
the disease.
 Anti viral therapy:
Current HAART options are combinations (or "cocktails") consisting of at
least three medications belonging to at least two types, or "classes",
of antiretroviral agents. Initially, treatment is typically a non-nucleoside
reverse transcriptase inhibitor (NNRTI) plus two nucleoside analog reverse
transcriptase inhibitors (NRTIs). Typical NRTIs include: zidovudine (AZT)
or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC). As of
2019, dolutegravir/lamivudine/tenofovir is listed by the World Health
Organization as the first-line treatment for adults,
with tenofovir/lamivudine/efavirenz as an alternative. Combinations of
agents that include protease inhibitors (PI) are used if the above regimen
loses effectiveness
 The World Health Organization and the United States recommend
antiretrovirals in people of all ages (including pregnant women) as soon as
the diagnosis is made, regardless of CD4 count.
 The desired outcome of treatment is a long-term plasma HIV-RNA count
below 50 copies/mL
 Levels to determine if treatment is effective are initially recommended after
four weeks and once levels fall below 50 copies/mL checks every three to
six months are typically adequate
 Inadequate control is deemed to be greater than 400 copies/mL.
 Based on these criteria treatment is effective in more than 95% of people
during the first year
 Benefits of treatment include a decreased risk of progression to AIDS and a
decreased risk of death
 The European Medicines Agency (EMA) has recommended the granting of
marketing authorizations for two new antiretroviral (ARV)
medicines, rilpivirine (Rekambys) and cabotegravir (Vocabria), to be used
together for the treatment of people with human immunodeficiency virus
type 1 (HIV-1) infection. The two medicines are the first ARVs that come in
a long-acting injectable formulation. This means that instead of daily pills,
people receive intramuscular injections monthly or every two months.
 The combination of Rekambys and Vocabria injection is intended for
maintenance treatment of adults who have undetectable HIV levels in the
 blood (viral load less than 50 copies/ml) with their current ARV treatment,
and when the virus has not developed resistance to a certain class of anti-
HIV medicines called non-nucleoside reverse transcriptase inhibitors
(NNRTIs) and integrase strand transfer inhibitors
 The World Health Organization (WHO) has issued recommendations
regarding nutrient requirements in HIV/AIDS.A generally healthy diet is
promoted. Dietary intake of micronutrients at RDA levels by HIV-infected
adults is recommended by the WHO; higher intake of vitamin A, zinc, and
iron can produce adverse effects in HIV-positive adults, and is not
recommended unless there is documented deficiency. Dietary
supplementation for people who are infected with HIV and who have
inadequate nutrition or dietary deficiencies may strengthen their immune
systems or help them recover from infections; however, evidence indicating
an overall benefit in morbidity or reduction in mortality is not consistent..
 People with HIV/AIDS are up to four times more likely to develop type
2 diabetes than those who are not tested positive with the virus.
 Evidence for supplementation with selenium is mixed with some tentative
evidence of benefit. For pregnant and lactating women with
HIV, multivitamin supplement improves outcomes for both mothers and
children.. If the pregnant or lactating mother has been advised to take anti-
retroviral medication to prevent mother-to-child HIV transmission,
multivitamin supplements should not replace these treatments. . There is
some evidence that vitamin A supplementation in children with an HIV
infection reduces mortality and improves growth.