HIV/AIDS

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HIV/AIDS
SynonymsHIV disease, HIV infection [1] [2]
Red Ribbon.svg
The red ribbon is a symbol for solidarity with HIV-positive people and those living with AIDS. [3]
Specialty Infectious disease
SymptomsEarly: flu like illness [4]
Later: Large lymph nodes, fever, weight loss [4]
Complications Opportunistic infections, tumors [4]
DurationLifelong [4]
Causes Human immunodeficiency virus (HIV) [4]
Risk factors Exposure to blood, breast milk, sex [4]
Diagnostic method Blood tests [4]
Prevention Safe sex, needle exchange, male circumcision, pre-exposure prophylaxis, post-exposure prophylaxis [4]
Treatment Antiretroviral therapy [4]
PrognosisNear normal life expectancy with treatment [5] [6]
11 years life expectancy without treatment [7]
Frequency1.8 million new cases (2016) [8]
36.7 million living with HIV (2016) [8]
Deaths1.0 million (2016) [8]

Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV). [9] [10] [11] Following initial infection, a person may not notice any symptoms or may experience a brief period of influenza-like illness. [4] Typically, this is followed by a prolonged period with no symptoms. [5] As the infection progresses, it interferes more with the immune system, increasing the risk of developing common infections such as tuberculosis, as well as other opportunistic infections, and tumors that rarely affect people who have uncompromised immune systems. [4] These late symptoms of infection are referred to as acquired immunodeficiency syndrome (AIDS). [5] This stage is often also associated with unintended weight loss. [5]

Infection invasion of a host by disease-causing organisms

Infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host tissues to the infectious agents and the toxins they produce. Infectious disease, also known as transmissible disease or communicable disease, is illness resulting from an infection.

HIV human retrovirus, cause of AIDS

The human immunodeficiency viruses (HIV) are two species of Lentivirus that causes HIV infection and over time acquired immunodeficiency syndrome (AIDS). AIDS is a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive. Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype. In most cases, HIV is a sexually transmitted infection and occurs by contact with or transfer of blood, pre-ejaculate, semen, and vaginal fluids. Non-sexual transmission can occur from an infected mother to her infant during pregnancy, during childbirth by exposure to her blood or vaginal fluid, and through breast milk. Within these bodily fluids, HIV is present as both free virus particles and virus within infected immune cells.

Influenza-like illness

Influenza-like illness (ILI), also known as acute respiratory infection (ARI) and flu-like syndrome/symptoms, is a medical diagnosis of possible influenza or other illness causing a set of common symptoms.

Contents

HIV is spread primarily by unprotected sex (including anal and oral sex), contaminated blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery, or breastfeeding. [12] Some bodily fluids, such as saliva and tears, do not transmit HIV. [13] Methods of prevention include safe sex, needle exchange programs, treating those who are infected, pre- and post-exposure prophylaxis, and male circumcision. [4] Disease in a baby can often be prevented by giving both the mother and child antiretroviral medication. [4] There is no cure or vaccine; however, antiretroviral treatment can slow the course of the disease and may lead to a near-normal life expectancy. [5] [6] Treatment is recommended as soon as the diagnosis is made. [14] Without treatment, the average survival time after infection is 11 years. [7]

Anal sex sexual practice

Anal sex or anal intercourse is generally the insertion and thrusting of the erect penis into a person's anus, or anus and rectum, for sexual pleasure. Other forms of anal sex include fingering, the use of sex toys for anal penetration, oral sex performed on the anus (anilingus), and pegging. Although anal sex most commonly means penile–anal penetration, sources sometimes use anal intercourse to exclusively denote penile–anal penetration, and anal sex to denote any form of anal sexual activity, especially between pairings as opposed to anal masturbation.

Oral sex sexual activity involving the stimulation of the genitalia by the use of the mouth

Oral sex, sometimes referred to as oral intercourse, is sexual activity involving the stimulation of the genitalia of a person by another person using the mouth or throat. Cunnilingus is oral sex performed on female genitals, while fellatio is oral sex performed on a penis. Anilingus, another form of oral sex, is oral stimulation of a person's anus. Oral stimulation of other parts of the body is usually not considered oral sex.

Blood transfusion generally the process of receiving blood or blood products into ones circulation intravenously

Blood transfusion is the process of transferring blood or blood products into one's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cells, white blood cells, plasma, clotting factors, and platelets.

In 2016, about 36.7 million people were living with HIV and it resulted in 1 million deaths. [15] There were 300,000 fewer new HIV cases in 2016 than in 2015. [16] Most of those infected live in sub-Saharan Africa. [4] From the time AIDS was identified in the early 1980s to 2017, the disease has caused an estimated 35 million deaths worldwide. [17] HIV/AIDS is considered a pandemic—a disease outbreak which is present over a large area and is actively spreading. [18] HIV originated in west-central Africa during the late 19th or early 20th century. [19] AIDS was first recognized by the United States Centers for Disease Control and Prevention (CDC) in 1981 and its cause—HIV infection—was identified in the early part of the decade. [20]

Sub-Saharan Africa area of the continent of Africa that lies south of the Sahara Desert

Sub-Saharan Africa is, geographically, the area of the continent of Africa that lies south of the Sahara. According to the United Nations, it consists of all African countries that are fully or partially located south of the Sahara. It contrasts with North Africa, whose territories are part of the League of Arab states within the Arab world. The states of Somalia, Djibouti, Comoros and the Arabic speaking Mauritania are however geographically in sub-Saharan Africa, although they are members of the Arab League as well. The UN Development Program lists 46 of Africa’s 54 countries as “sub-Saharan,” excluding Algeria, Djibouti, Egypt, Libya, Morocco, Somalia, Sudan and Tunisia.

Pandemic global epidemic of infectious disease

A pandemic is an epidemic of disease that has spread across a large region; for instance multiple continents, or even worldwide. This may include communicable and noncommunicable diseases.

Centers for Disease Control and Prevention government agency

The Centers for Disease Control and Prevention (CDC) is the leading national public health institute of the United States. The CDC is a United States federal agency under the Department of Health and Human Services and is headquartered in Atlanta, Georgia.

HIV/AIDS has had a large impact on society, both as an illness and as a source of discrimination. [21] The disease also has large economic impacts. [21] There are many misconceptions about HIV/AIDS such as the belief that it can be transmitted by casual non-sexual contact. [22] The disease has become subject to many controversies involving religion including the Catholic Church's position not to support condom use as prevention. [23] It has attracted international medical and political attention as well as large-scale funding since it was identified in the 1980s. [24]

Discrimination against people with HIV/AIDS or serophobia is the prejudice, fear, rejection and discrimination against people living with HIV/AIDS (PLHIV). Discrimination is one manifestation of stigma, and stigmatizing attitudes and behaviors may fall under the rubric of discrimination depending on the legislation of a particular country. HIV stands for human immunodeficiency virus. If left untreated, HIV can lead to the disease AIDS. HIV/AIDS is a sexually transmitted disease and cannot be cured, but with proper treatment, the individual can live just as long as without the disease.

Economic impact of HIV/AIDS

HIV and AIDS affects economic growth by reducing the availability of human capital. Without proper prevention, nutrition, health care and medicine that is available in developing countries, large numbers of people are falling victim to AIDS.

Misconceptions about HIV/AIDS

The spread of HIV/AIDS has affected millions of people worldwide; AIDS is considered a pandemic. The World Health Organization (WHO) estimated that in 2016 there were 36.7 million people worldwide living with HIV/AIDS, with 1.8 million new HIV infections per year and 1 million deaths due to AIDS. In 2016, UNAIDS estimated: 2.1 million children worldwide were living with HIV/ AIDS and 17.8 million women worldwide were living with HIV/ AIDS. In 2011, UNAIDS estimated: 1.8 million new HIV infections in sub-Saharan Africa compared to 2.4 million new infections in 2001 a 25% decline. Between 2005-2011, the number of deaths from AIDS-related causes in sub-Saharan Africa declined by 32%,1.8 million to 1.2 million. From 2009 and 2011, the number of children newly infected with HIV fell in sub-Saharan Africa fell by 24%

Signs and symptoms

There are three main stages of HIV infection: acute infection, clinical latency, and AIDS. [1] [25]

Acute infection

Main symptoms of acute HIV infection Symptoms of acute HIV infection.svg
Main symptoms of acute HIV infection

The initial period following the contraction of HIV is called acute HIV, primary HIV or acute retroviral syndrome. [25] [26] Many individuals develop an influenza-like illness or a mononucleosis-like illness 2–4 weeks after exposure while others have no significant symptoms. [27] [28] Symptoms occur in 40–90% of cases and most commonly include fever, large tender lymph nodes, throat inflammation, a rash, headache, tiredness, and/or sores of the mouth and genitals. [26] [28] The rash, which occurs in 20–50% of cases, presents itself on the trunk and is maculopapular, classically. [29] Some people also develop opportunistic infections at this stage. [26] Gastrointestinal symptoms, such as vomiting or diarrhea may occur. [28] Neurological symptoms of peripheral neuropathy or Guillain–Barré syndrome also occurs. [28] The duration of the symptoms varies, but is usually one or two weeks. [28]

Infectious mononucleosis common viral infectious disease

Infectious mononucleosis, also known as glandular fever, is an infection usually caused by the Epstein–Barr virus (EBV). Most people are infected by the virus as children, when the disease produces few or no symptoms. In young adults, the disease often results in fever, sore throat, enlarged lymph nodes in the neck, and tiredness. Most people recover in two to four weeks; however, feeling tired may last for months. The liver or spleen may also become swollen, and in less than one percent of cases splenic rupture may occur.

Fever common medical sign characterized by elevated body temperature

Fever, also known as pyrexia and febrile response, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using values between 37.5 and 38.3 °C. The increase in set point triggers increased muscle contractions and causes a feeling of cold. This results in greater heat production and efforts to conserve heat. When the set point temperature returns to normal, a person feels hot, becomes flushed, and may begin to sweat. Rarely a fever may trigger a febrile seizure. This is more common in young children. Fevers do not typically go higher than 41 to 42 °C.

Lymphadenopathy disorder of lymph nodes

Lymphadenopathy or adenopathy is disease of the lymph nodes, in which they are abnormal in size or consistency. Lymphadenopathy of an inflammatory type is lymphadenitis, producing swollen or enlarged lymph nodes. In clinical practice, the distinction between lymphadenopathy and lymphadenitis is rarely made and the words are usually treated as synonymous. Inflammation of the lymphatic vessels is known as lymphangitis. Infectious lymphadenitis affecting lymph nodes in the neck is often called scrofula.

Due to their nonspecific character, these symptoms are not often recognized as signs of HIV infection. Even cases that do get seen by a family doctor or a hospital are often misdiagnosed as one of the many common infectious diseases with overlapping symptoms. Thus, it is recommended that HIV be considered in people presenting with an unexplained fever who may have risk factors for the infection. [28]

Clinical latency

The initial symptoms are followed by a stage called clinical latency, asymptomatic HIV, or chronic HIV. [1] Without treatment, this second stage of the natural history of HIV infection can last from about three years [30] to over 20 years [31] (on average, about eight years). [32] While 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. [1] 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. [25]

Although most HIV-1 infected individuals have a detectable viral load and in the absence of treatment will eventually progress to AIDS, a small proportion (about 5%) retain high levels of CD4+ T cells (T helper cells) without antiretroviral therapy for more than 5 years. [28] [33] These individuals are classified as "HIV controllers" or long-term nonprogressors (LTNP). [33] Another group consists of those who maintain a low or undetectable viral load without anti-retroviral treatment, known as "elite controllers" or "elite suppressors". They represent approximately 1 in 300 infected persons. [34]

Acquired immunodeficiency syndrome

Main symptoms of AIDS. Symptoms of AIDS.svg
Main symptoms of AIDS.

Acquired immunodeficiency syndrome (AIDS) is defined in terms of either a CD4+ T cell count below 200 cells per µL or the occurrence of specific diseases in association with an HIV infection. [28] In the absence of specific treatment, around half of people infected with HIV develop AIDS within ten years. [28] 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. [28] Other common signs include recurrent respiratory tract infections. [28]

Opportunistic infections may be caused by bacteria, viruses, fungi, and parasites that are normally controlled by the immune system. [35] Which infections occur depends partly on what organisms are common in the person's environment. [28] These infections may affect nearly every organ system. [36]

People with AIDS have an increased risk of developing various viral-induced cancers, including Kaposi's sarcoma, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer. [29] Kaposi's sarcoma is the most common cancer occurring in 10 to 20% of people with HIV. [37] The second most common cancer is lymphoma, which is the cause of death of nearly 16% of people with AIDS and is the initial sign of AIDS in 3 to 4%. [37] Both these cancers are associated with human herpesvirus 8 (HHV-8). [37] Cervical cancer occurs more frequently in those with AIDS because of its association with human papillomavirus (HPV). [37] Conjunctival cancer (of the layer that lines the inner part of eyelids and the white part of the eye) is also more common in those with HIV. [38]

Additionally, people with AIDS frequently have systemic symptoms such as prolonged fevers, sweats (particularly at night), swollen lymph nodes, chills, weakness, and unintended weight loss. [39] Diarrhea is another common symptom, present in about 90% of people with AIDS. [40] They can also be affected by diverse psychiatric and neurological symptoms independent of opportunistic infections and cancers. [41]

Transmission

Average per act risk of getting HIV
by exposure route to an infected source
Exposure routeChance of infection
Blood transfusion90% [42] [ not in citation given ]
Childbirth (to child)25% [43] [ clarification needed ]
Needle-sharing injection drug use0.67% [42]
Percutaneous needle stick0.30% [44]
Receptive anal intercourse*0.04–3.0% [45]
Insertive anal intercourse*0.03% [46]
Receptive penile-vaginal intercourse*0.05–0.30% [45] [47]
Insertive penile-vaginal intercourse*0.01–0.38% [45] [47]
Receptive oral intercourse0–0.04% [45]
Insertive oral intercourse0–0.005% [48]
* assuming no condom use
§ source refers to oral intercourse
performed on a man

HIV is spread by three main routes: sexual contact, significant exposure to infected body fluids or tissues, and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission). [12] 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. [49] It is also possible to be co-infected by more than one strain of HIV—a condition known as HIV superinfection. [50]

Sexual

The most frequent mode of transmission of HIV is through sexual contact with an infected person. [12] However, an HIV-positive person who has an undetectable viral load as a result of long-term treatment has effectively no risk of transmitting HIV sexually. [51] [52] Globally, the most common mode of HIV transmission is via sexual contacts between people of the opposite sex; [12] however, the pattern of transmission varies among countries. As of 2014, most HIV transmission in the United States occurred among men who had sex with men (83% of new HIV diagnoses among males aged 13 and older and 67% of total new diagnoses). [53] In the US, gay and bisexual men aged 13 to 24 accounted for an estimated 92% of new HIV diagnoses among all men in their age group and 27% of new diagnoses among all gay and bisexual men. [53] About 15% of gay and bisexual men have HIV while 28% of transgender women test positive in the US. [53] [54]

With regard to unprotected heterosexual contacts, estimates of the risk of HIV transmission per sexual act appear to be four to ten times higher in low-income countries than in high-income countries. [55] In low-income countries, the risk of female-to-male transmission is estimated as 0.38% per act, and of male-to-female transmission as 0.30% per act; the equivalent estimates for high-income countries are 0.04% per act for female-to-male transmission, and 0.08% per act for male-to-female transmission. [55] The risk of transmission from anal intercourse is especially high, estimated as 1.41.7% per act in both heterosexual and homosexual contacts. [55] [56] While the risk of transmission from oral sex is relatively low, it is still present. [57] The risk from receiving oral sex has been described as "nearly nil"; [58] however, a few cases have been reported. [59] The per-act risk is estimated at 00.04% for receptive oral intercourse. [60] In settings involving prostitution in low income countries, risk of female-to-male transmission has been estimated as 2.4% per act and male-to-female transmission as 0.05% per act. [55]

Risk of transmission increases in the presence of many sexually transmitted infections [61] and genital ulcers. [55] Genital ulcers appear to increase the risk approximately fivefold. [55] Other sexually transmitted infections, such as gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis, are associated with somewhat smaller increases in risk of transmission. [60]

The viral load of an infected person is an important risk factor in both sexual and mother-to-child transmission. [62] During the first 2.5 months of an HIV infection a person's infectiousness is twelve times higher due to the high viral load associated with acute HIV. [60] If the person is in the late stages of infection, rates of transmission are approximately eightfold greater. [55]

Commercial sex workers (including those in pornography) have an increased likelihood of contracting HIV. [63] [64] Rough sex can be a factor associated with an increased risk of transmission. [65] Sexual assault is also believed to carry an increased risk of HIV transmission as condoms are rarely worn, physical trauma to the vagina or rectum is likely, and there may be a greater risk of concurrent sexually transmitted infections. [66]

Body fluids

CDC poster from 1989 highlighting the threat of AIDS associated with drug use AIDS Poster If You're Dabbling in Drugs 1989.jpg
CDC poster from 1989 highlighting the threat of AIDS associated with drug use

The second most frequent mode of HIV transmission is via blood and blood products. [12] Blood-borne transmission can be through needle-sharing during intravenous drug use, needle stick injury, transfusion of contaminated blood or blood product, or medical injections with unsterilized equipment. The risk from sharing a needle during drug injection is between 0.63 and 2.4% per act, with an average of 0.8%. [67] The risk of acquiring HIV from a needle stick from an HIV-infected person is estimated as 0.3% (about 1 in 333) per act and the risk following mucous membrane exposure to infected blood as 0.09% (about 1 in 1000) per act. [49] In the United States intravenous drug users made up 12% of all new cases of HIV in 2009, [68] and in some areas more than 80% of people who inject drugs are HIV positive. [12]

HIV is transmitted in about 93% of blood transfusions using infected blood. [67] In developed countries the risk of acquiring HIV from a blood transfusion is extremely low (less than one in half a million) where improved donor selection and HIV screening is performed; [12] for example, in the UK the risk is reported at one in five million [69] and in the United States it was one in 1.5 million in 2008. [70] In low income countries, only half of transfusions may be appropriately screened (as of 2008), [71] and it is estimated that up to 15% of HIV infections in these areas come from transfusion of infected blood and blood products, representing between 5% and 10% of global infections. [12] [72] Although rare because of screening, it is possible to acquire HIV from organ and tissue transplantation. [73]

Unsafe medical injections play a significant role in HIV spread in sub-Saharan Africa. In 2007, between 12 and 17% of infections in this region were attributed to medical syringe use. [74] The World Health Organization estimates the risk of transmission as a result of a medical injection in Africa at 1.2%. [74] Significant risks are also associated with invasive procedures, assisted delivery, and dental care in this area of the world. [74]

People giving or receiving tattoos, piercings, and scarification are theoretically at risk of infection but no confirmed cases have been documented. [75] It is not possible for mosquitoes or other insects to transmit HIV. [76]

Mother-to-child

HIV can be transmitted from mother to child during pregnancy, during delivery, or through breast milk, resulting in the baby also contracting HIV. [77] [78] This is the third most common way in which HIV is transmitted globally. [12] In the absence of treatment, the risk of transmission before or during birth is around 20% and in those who also breastfeed 35%. [78] As of 2008, vertical transmission accounted for about 90% of cases of HIV in children. [78] With appropriate treatment the risk of mother-to-child infection can be reduced to about 1%. [78] Preventive treatment involves the mother taking antiretrovirals during pregnancy and delivery, an elective caesarean section, avoiding breastfeeding, and administering antiretroviral drugs to the newborn. [79] Antiretrovirals when taken by either the mother or the infant decrease the risk of transmission in those who do breastfeed. [80] However, many of these measures are not available in the developing world. [79] If blood contaminates food during pre-chewing it may pose a risk of transmission. [75]

If a woman is untreated, two years of breastfeeding results in an HIV/AIDS risk in her baby of about 17%. Treatment decreases this risk to 1 to 2% per year. Due to the increased risk of death without breastfeeding in many areas in the developing world, the World Health Organization recommends either: (1) the mother and baby being treated with antiretroviral medication while breastfeeding being continued (2) the provision of safe formula. [81] Infection with HIV during pregnancy is also associated with miscarriage. [82]

Virology

Diagram of a HIV virion structure HI-virion-structure en.svg
Diagram of a HIV virion structure
Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte. HIV-budding-Color.jpg
Scanning electron micrograph of HIV-1, colored green, budding from a cultured lymphocyte.

HIV is the cause of the spectrum of disease known as HIV/AIDS. HIV is a retrovirus that primarily infects components of the human immune system such as CD4+ T cells, macrophages and dendritic cells. It directly and indirectly destroys CD4+ T cells. [83]

HIV is a member of the genus Lentivirus , [84] part of the family Retroviridae . [85] Lentiviruses share many morphological and biological characteristics. Many species of mammals are infected by lentiviruses, which are characteristically responsible for long-duration illnesses with a long incubation period. [86] Lentiviruses are transmitted as single-stranded, positive-sense, enveloped RNA viruses. Upon entry into the target cell, the viral RNA genome is converted (reverse transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle. The resulting viral DNA is then imported into the cell nucleus and integrated into the cellular DNA by a virally encoded integrase and host co-factors. [87] Once integrated, the virus may become latent, allowing the virus and its host cell to avoid detection by the immune system. [88] Alternatively, the virus may be transcribed, producing new RNA genomes and viral proteins that are packaged and released from the cell as new virus particles that begin the replication cycle anew. [89]

HIV is now known to spread between CD4+ T cells by two parallel routes: cell-free spread and cell-to-cell spread, i.e. it employs hybrid spreading mechanisms. [90] In the cell-free spread, virus particles bud from an infected T cell, enter the blood/extracellular fluid and then infect another T cell following a chance encounter. [90] HIV can also disseminate by direct transmission from one cell to another by a process of cell-to-cell spread. [91] [92] The hybrid spreading mechanisms of HIV contribute to the virus's ongoing replication against antiretroviral therapies. [90] [93]

Two types of HIV have been characterized: HIV-1 and HIV-2. HIV-1 is the virus that was originally discovered (and initially referred to also as LAV or HTLV-III). It is more virulent, more infective, [94] and is the cause of the majority of HIV infections globally. The lower infectivity of HIV-2 as compared with HIV-1 implies that fewer people exposed to HIV-2 will be infected per exposure. Because of its relatively poor capacity for transmission, HIV-2 is largely confined to West Africa. [95]

Pathophysiology

HIV/AIDS explained in a simple way
HIV replication cycle Hiv replication cycle.gif
HIV replication cycle

After the virus enters the body there is a period of rapid viral replication, leading to an abundance of virus in the peripheral blood. During primary infection, the level of HIV may reach several million virus particles per milliliter of blood. [96] 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. [97]

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. [98] During the acute phase, HIV-induced cell lysis and killing of infected cells by cytotoxic 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. [99]

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. [100] The reason for the preferential loss of mucosal CD4+ T cells is that the majority of mucosal CD4+ T cells express the CCR5 protein which HIV uses as a co-receptor to gain access to the cells, whereas only a small fraction of CD4+ T cells in the bloodstream do so. [101] A specific genetic change that alters the CCR5 protein when present in both chromosomes very effectively prevents HIV-1 infection. [102]

HIV seeks out and destroys CCR5 expressing CD4+ T cells during acute infection. [103] A vigorous immune response eventually controls the infection and initiates the clinically latent phase. CD4+ T cells in mucosal tissues remain particularly affected. [103] Continuous HIV replication causes a state of generalized immune activation persisting throughout the chronic phase. [104] Immune activation, which is reflected by the increased activation state of immune cells and release of pro-inflammatory cytokines, results from the activity of several HIV gene products and the immune response to ongoing HIV replication. It is also linked to the breakdown of the immune surveillance system of the gastrointestinal mucosal barrier caused by the depletion of mucosal CD4+ T cells during the acute phase of disease. [105]

Diagnosis

A generalized graph of the relationship between HIV copies (viral load) and CD4 T cell counts over the average course of untreated HIV infection.
CD4 T Lymphocyte count (cells/mm3)
HIV RNA copies per mL of plasma Hiv-timecourse.png
A generalized graph of the relationship between HIV copies (viral load) and CD4 T cell counts over the average course of untreated HIV infection.
  CD4 T Lymphocyte count (cells/mm³)
  HIV RNA copies per mL of plasma
Days after exposure needed for the test to be accurate [106]
Blood testDays
Antibody test (rapid test, ELISA 3rd gen)23–90
Antibody and p24 antigen test (ELISA 4th gen)18–45
PCR10–33

HIV/AIDS is diagnosed via laboratory testing and then staged based on the presence of certain signs or symptoms. [26] HIV screening is recommended by the United States Preventive Services Task Force for all people 15 years to 65 years of age including all pregnant women. [107] Additionally, testing is recommended for those at high risk, which includes anyone diagnosed with a sexually transmitted illness. [29] In many areas of the world, a third of HIV carriers only discover they are infected at an advanced stage of the disease when AIDS or severe immunodeficiency has become apparent. [29]

HIV testing

Most people infected with HIV develop specific antibodies (i.e. seroconvert) within three to twelve weeks after the initial infection. [28] Diagnosis of primary HIV before seroconversion is done by measuring HIV-RNA or p24 antigen. [28] Positive results obtained by antibody or PCR testing are confirmed either by a different antibody or by PCR. [26]

Antibody tests in children younger than 18 months are typically inaccurate due to the continued presence of maternal antibodies. [108] Thus HIV infection can only be diagnosed by PCR testing for HIV RNA or DNA, or via testing for the p24 antigen. [26] Much of the world lacks access to reliable PCR testing and many places simply wait until either symptoms develop or the child is old enough for accurate antibody testing. [108] In sub-Saharan Africa as of 2007–2009, between 30 and 70% of the population were aware of their HIV status. [109] In 2009, between 3.6 and 42% of men and women in Sub-Saharan countries were tested [109] which represented a significant increase compared to previous years. [109]

Classifications

Two main clinical staging systems are used to classify HIV and HIV-related disease for surveillance purposes: the WHO disease staging system for HIV infection and disease, [26] and the CDC classification system for HIV infection. [110] The CDC's classification system is more frequently adopted in developed countries. Since the WHO's staging system does not require laboratory tests, it is suited to the resource-restricted conditions encountered in developing countries, where it can also be used to help guide clinical management. Despite their differences, the two systems allow comparison for statistical purposes. [25] [26] [110]

The World Health Organization first proposed a definition for AIDS in 1986. [26] Since then, the WHO classification has been updated and expanded several times, with the most recent version being published in 2007. [26] The WHO system uses the following categories:

The United States Center for Disease Control and Prevention also created a classification system for HIV, and updated it in 2008 and 2014. [110] [111] This system classifies HIV infections based on CD4 count and clinical symptoms, and describes the infection in five groups. [111] In those greater than six years of age it is: [111]

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. [25]

Prevention

AIDS Clinic, McLeod Ganj, Himachal Pradesh, India, 2010 AIDS Clinic, McLeod Ganj, 2010.jpg
AIDS Clinic, McLeod Ganj, Himachal Pradesh, India, 2010

Sexual contact

Consistent condom use reduces the risk of HIV transmission by approximately 80% over the long term. [112] When condoms are used consistently by a couple in which one person is infected, the rate of HIV infection is less than 1% per year. [113] There is some evidence to suggest that female condoms may provide an equivalent level of protection. [114] 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. [115] By contrast, use of the spermicide nonoxynol-9 may increase the risk of transmission due to its tendency to cause vaginal and rectal irritation. [116]

Circumcision in Sub-Saharan Africa "reduces the acquisition of HIV by heterosexual men by between 38% and 66% over 24 months". [117] Due to these studies, both the World Health Organization and UNAIDS recommended male circumcision in 2007 as a method of preventing female-to-male HIV transmission in areas with high rates of HIV. [118] However, whether it protects against male-to-female transmission is disputed, [119] [120] and whether it is of benefit in developed countries and among men who have sex with men is undetermined. [121] [122] [123] The International Antiviral Society, however, does recommend it for all sexually active heterosexual males and that it be discussed as an option with men who have sex with men. [124] Some experts fear that a lower perception of vulnerability among circumcised men may cause more sexual risk-taking behavior, thus negating its preventive effects. [125]

Programs encouraging sexual abstinence do not appear to affect subsequent HIV risk. [126] Evidence of any benefit from peer education is equally poor. [127] Comprehensive sexual education provided at school may decrease high risk behavior. [128] [129] A substantial minority of young people continues to engage in high-risk practices despite knowing about HIV/AIDS, underestimating their own risk of becoming infected with HIV. [130] Voluntary counseling and testing people for HIV does not affect risky behavior in those who test negative but does increase condom use in those who test positive. [131] It is not known whether treating other sexually transmitted infections is effective in preventing HIV. [61]

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 (a strategy known as treatment as prevention, or TASP). [132] TASP is associated with a 10 to 20 fold reduction in transmission risk. [132] [133] Pre-exposure prophylaxis (PrEP) with a daily dose of the medications tenofovir, with or without emtricitabine, is effective in a number of groups including men who have sex with men, couples where one is HIV positive, and young heterosexuals in Africa. [115] It may also be effective in intravenous drug users with a study finding a decrease in risk of 0.7 to 0.4 per 100 person years. [134] The USPSTF, ini a 2018 draft, recommended PrEP in those who are at high risk. [135]

Universal precautions within the health care environment are believed to be effective in decreasing the risk of HIV. [136] Intravenous drug use is an important risk factor and harm reduction strategies such as needle-exchange programs and opioid substitution therapy appear effective in decreasing this risk. [137] [138]

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). [139] The use of the single agent zidovudine reduces the risk of a HIV infection five-fold following a needle-stick injury. [139] As of 2013, the prevention regimen recommended in the United States consists of three medications—tenofovir, emtricitabine and raltegravir—as this may reduce the risk further. [140]

PEP treatment is recommended after a sexual assault when the perpetrator is known to be HIV positive, but is controversial when their HIV status is unknown. [141] The duration of treatment is usually four weeks [142] and is frequently associated with adverse effects—where zidovudine is used, about 70% of cases result in adverse effects such as nausea (24%), fatigue (22%), emotional distress (13%) and headaches (9%). [49]

Mother-to-child

Programs to prevent the vertical transmission of HIV (from mothers to children) can reduce rates of transmission by 92–99%. [78] [137] This primarily involves the use of a combination of antiviral medications during pregnancy and after birth in the infant and potentially includes bottle feeding rather than breastfeeding. [78] [143] If replacement feeding is acceptable, feasible, affordable, sustainable, and safe, mothers should avoid breastfeeding their infants; however exclusive breastfeeding is recommended during the first months of life if this is not the case. [144] If exclusive breastfeeding is carried out, the provision of extended antiretroviral prophylaxis to the infant decreases the risk of transmission. [145] In 2015, Cuba became the first country in the world to eradicate mother-to-child transmission of HIV. [146]

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 and 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. [147] Further trials of the RV 144 vaccine are ongoing. [148] [149]

Treatment

There is currently no cure or effective HIV vaccine. Treatment consists of highly active antiretroviral therapy (HAART) which slows progression of the disease. [150] As of 2010 more than 6.6 million people were taking them in low and middle income countries. [151] Treatment also includes preventive and active treatment of opportunistic infections.

Antiviral therapy

Stribild - a common once-daily ART regime consisting of elvitegravir, emtricitabine, tenofovir and the booster cobicistat Stribild bottle Dutch labeling.jpg
Stribild – a common once-daily ART regime consisting of elvitegravir, emtricitabine, tenofovir and the booster cobicistat

Current HAART options are combinations (or "cocktails") consisting of at least three medications belonging to at least two types, or "classes," of antiretroviral agents. [152] Initially treatment is typically a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two nucleoside analog reverse transcriptase inhibitors (NRTIs). [153] Typical NRTIs include: zidovudine (AZT) or tenofovir (TDF) and lamivudine (3TC) or emtricitabine (FTC). [153] Combinations of agents which include protease inhibitors (PI) are used if the above regimen loses effectiveness. [152]

The World Health Organization and United States recommends antiretrovirals in people of all ages including pregnant women as soon as the diagnosis is made regardless of CD4 count. [14] [124] [154] Once treatment is begun it is recommended that it is continued without breaks or "holidays". [29] Many people are diagnosed only after treatment ideally should have begun. [29] The desired outcome of treatment is a long term plasma HIV-RNA count below 50 copies/mL. [29] 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. [29] Inadequate control is deemed to be greater than 400 copies/mL. [29] Based on these criteria treatment is effective in more than 95% of people during the first year. [29]

Benefits of treatment include a decreased risk of progression to AIDS and a decreased risk of death. [155] In the developing world treatment also improves physical and mental health. [156] With treatment there is a 70% reduced risk of acquiring tuberculosis. [152] Additional benefits include a decreased risk of transmission of the disease to sexual partners and a decrease in mother-to-child transmission. [152] [157] The effectiveness of treatment depends to a large part on compliance. [29] Reasons for non-adherence include poor access to medical care, [158] inadequate social supports, mental illness and drug abuse. [159] The complexity of treatment regimens (due to pill numbers and dosing frequency) and adverse effects may reduce adherence. [160] Even though cost is an important issue with some medications, [161] 47% of those who needed them were taking them in low and middle income countries as of 2010 [151] and the rate of adherence is similar in low-income and high-income countries. [162]

Specific adverse events are related to the antiretroviral agent taken. [163] Some relatively common adverse events include: lipodystrophy syndrome, dyslipidemia, and diabetes mellitus, especially with protease inhibitors. [25] Other common symptoms include diarrhea, [163] [164] and an increased risk of cardiovascular disease. [165] Newer recommended treatments are associated with fewer adverse effects. [29] Certain medications may be associated with birth defects and therefore may be unsuitable for women hoping to have children. [29]

Treatment recommendations for children are somewhat different from those for adults. The World Health Organization recommends treating all children less than 5 years of age; children above 5 are treated like adults. [166] The United States guidelines recommend treating all children less than 12 months of age and all those with HIV RNA counts greater than 100,000 copies/mL between one year and five years of age. [167]

Opportunistic infections

Measures to prevent opportunistic infections are effective in many people with HIV/AIDS. In addition to improving current disease, treatment with antiretrovirals reduces the risk of developing additional opportunistic infections. [163] Adults and adolescents who are living with HIV (even on anti-retroviral therapy) with no evidence of active tuberculosis in settings with high tuberculosis burden should receive isoniazid preventive therapy (IPT), the tuberculin skin test can be used to help decide if IPT is needed. [168] Vaccination against hepatitis A and B is advised for all people at risk of HIV before they become infected; however it may also be given after infection. [169] Trimethoprim/sulfamethoxazole prophylaxis between four and six weeks of age and ceasing breastfeeding in infants born to HIV positive mothers is recommended in resource limited settings. [170] It is also recommended to prevent PCP when a person's CD4 count is below 200 cells/uL and in those who have or have previously had PCP. [171] People with substantial immunosuppression are also advised to receive prophylactic therapy for toxoplasmosis and MAC. [172] Appropriate preventive measures have reduced the rate of these infections by 50% between 1992 and 1997. [173] Influenza vaccination and pneumococcal polysaccharide vaccine are often recommended in people with HIV/AIDS with some evidence of benefit. [174] [175]

Diet

The World Health Organization (WHO) has issued recommendations regarding nutrient requirements in HIV/AIDS. [176] 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. [176] [177] [178] [179] 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. [180]

Evidence for supplementation with selenium is mixed with some tentative evidence of benefit. [181] For pregnant and lactating women with HIV, multivitamin supplement improves outcomes for both mothers and children. [182] 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. [182] There is some evidence that vitamin A supplementation in children with an HIV infection reduces mortality and improves growth. [183]

Alternative medicine

In the US, approximately 60% of people with HIV use various forms of complementary or alternative medicine, [184] even though the effectiveness of most of these therapies has not been established. [185] There is not enough evidence to support the use of herbal medicines. [186] There is insufficient evidence to recommend or support the use of medical cannabis to try to increase appetite or weight gain. [187]

Prognosis

Deaths due to HIV/AIDS per million persons in 2012
.mw-parser-output .refbegin{font-size:90%;margin-bottom:0.5em}.mw-parser-output .refbegin-hanging-indents>ul{list-style-type:none;margin-left:0}.mw-parser-output .refbegin-hanging-indents>ul>li,.mw-parser-output .refbegin-hanging-indents>dl>dd{margin-left:0;padding-left:3.2em;text-indent:-3.2em;list-style:none}.mw-parser-output .refbegin-100{font-size:100%}
0
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Deaths due to HIV/AIDS per million persons in 2012
  0
  1–4
  5–12
  13–34
  35–61
  62–134
  135–215
  216–458
  459–1,402
  1,403–5,828

HIV/AIDS has become a chronic rather than an acutely fatal disease in many areas of the world. [188] Prognosis varies between people, and both the CD4 count and viral load are useful for predicted outcomes. [28] Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype. [7] After the diagnosis of AIDS, if treatment is not available, survival ranges between 6 and 19 months. [189] [190] HAART and appropriate prevention of opportunistic infections reduces the death rate by 80%, and raises the life expectancy for a newly diagnosed young adult to 20–50 years. [188] [191] [192] This is between two thirds [191] and nearly that of the general population. [29] [193] If treatment is started late in the infection, prognosis is not as good: [29] for example, if treatment is begun following the diagnosis of AIDS, life expectancy is ~10–40 years. [29] [188] Half of infants born with HIV die before two years of age without treatment. [170]

Disability-adjusted life year for HIV and AIDS per 100,000 inhabitants as of 2004.
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<= 10
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100-500
500-1000
1,000-2,500
2,500-5,000
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7,500-10,000
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>= 50,000 HIV-AIDS world map - DALY - WHO2004.svg
Disability-adjusted life year for HIV and AIDS per 100,000 inhabitants as of 2004.

The primary causes of death from HIV/AIDS are opportunistic infections and cancer, both of which are frequently the result of the progressive failure of the immune system. [173] [194] Risk of cancer appears to increase once the CD4 count is below 500/μL. [29] The rate of clinical disease progression varies widely between individuals and has been shown to be affected by a number of factors such as a person's susceptibility and immune function; [195] their access to health care, the presence of co-infections; [189] [196] and the particular strain (or strains) of the virus involved. [197] [198]

Tuberculosis co-infection is one of the leading causes of sickness and death in those with HIV/AIDS being present in a third of all HIV-infected people and causing 25% of HIV-related deaths. [199] HIV is also one of the most important risk factors for tuberculosis. [200] Hepatitis C is another very common co-infection where each disease increases the progression of the other. [201] The two most common cancers associated with HIV/AIDS are Kaposi's sarcoma and AIDS-related non-Hodgkin's lymphoma. [194] Other cancers that are more frequent include anal cancer, Burkitt's lymphoma, primary central nervous system lymphoma, and cervical cancer. [29] [202]

Even with anti-retroviral treatment, over the long term HIV-infected people may experience neurocognitive disorders, [203] osteoporosis, [204] neuropathy, [205] cancers, [206] [207] nephropathy, [208] and cardiovascular disease. [164] Some conditions, such as lipodystrophy, may be caused both by HIV and its treatment. [164]

Epidemiology

Estimated percentage of HIV among young adults (15-49) per country as of 2011
.
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15-50 AIDS and HIV prevalence 2008.svg
Estimated percentage of HIV among young adults (15–49) per country as of 2011.

HIV/AIDS is a global pandemic. [210] As of 2016, approximately 36.7 million people have HIV worldwide with the number of new infections that year being about 1.8 million. [15] This is down from 3.1 million new infections in 2001. [211] Slightly over half the infected population are women and 2.1 million are children. [15] It resulted in about 1 million deaths in 2016, down from a peak of 1.9 million in 2005. [15]

Sub-Saharan Africa is the region most affected. In 2010, an estimated 68% (22.9 million) of all HIV cases and 66% of all deaths (1.2 million) occurred in this region. [212] This means that about 5% of the adult population is infected [213] and it is believed to be the cause of 10% of all deaths in children. [214] Here in contrast to other regions women compose nearly 60% of cases. [212] South Africa has the largest population of people with HIV of any country in the world at 5.9 million. [212] Life expectancy has fallen in the worst-affected countries due to HIV/AIDS; for example, in 2006 it was estimated that it had dropped from 65 to 35 years in Botswana. [18] Mother-to-child transmission, as of 2013, in Botswana and South Africa has decreased to less than 5% with improvement in many other African nations due to improved access to antiretroviral therapy. [215]

South & South East Asia is the second most affected; in 2010 this region contained an estimated 4 million cases or 12% of all people living with HIV resulting in approximately 250,000 deaths. [213] Approximately 2.4 million of these cases are in India. [212]

In 2008 in the United States approximately 1.2 million people were living with HIV, resulting in about 17,500 deaths. The US Centers for Disease Control and Prevention estimated that in 2008 20% of infected Americans were unaware of their infection. [216] As of 2016 about 675,000 people have died of HIV/AIDS in the US since the beginning of the HIV epidemic. [54] In the United Kingdom as of 2015 there were approximately 101,200 cases which resulted in 594 deaths. [217] In Canada as of 2008 there were about 65,000 cases causing 53 deaths. [218] Between the first recognition of AIDS in 1981 and 2009 it has led to nearly 30 million deaths. [219] Prevalence is lowest in Middle East and North Africa at 0.1% or less, East Asia at 0.1% and Western and Central Europe at 0.2%. [213] The worst affected European countries, in 2009 and 2012 estimates, are Russia, Ukraine, Latvia, Moldova, Portugal and Belarus, in decreasing order of prevalence. [220]

History

Discovery

The Morbidity and Mortality Weekly Report reported in 1981 on what was later to be called "AIDS". Mmwr-aids-July1981-report-101.png
The Morbidity and Mortality Weekly Report reported in 1981 on what was later to be called "AIDS".

AIDS was first clinically reported on June 5th 1981 with 5 cases in the United States. [37] [221] The initial cases were a cluster of injecting drug users and homosexual men with no known cause of impaired immunity who showed symptoms of Pneumocystis carinii pneumonia (PCP), a rare opportunistic infection that was known to occur in people with very compromised immune systems. [222] Soon thereafter, an unexpected number of homosexual men developed a previously rare skin cancer called Kaposi's sarcoma (KS). [223] [224] Many more cases of PCP and KS emerged, alerting U.S. Centers for Disease Control and Prevention (CDC) and a CDC task force was formed to monitor the outbreak. [225]

In the early days, the CDC did not have an official name for the disease, often referring to it by way of the diseases that were associated with it, for example, lymphadenopathy, the disease after which the discoverers of HIV originally named the virus. [226] [227] They also used Kaposi's sarcoma and opportunistic infections, the name by which a task force had been set up in 1981. [228] At one point, the CDC coined the phrase "the 4H disease", since the syndrome seemed to affect heroin users, homosexuals, hemophiliacs, and Haitians. [229] [230] In the general press, the term "GRID", which stood for gay-related immune deficiency, had been coined. [231] However, after determining that AIDS was not isolated to the gay community, [228] it was realized that the term GRID was misleading and the term AIDS was introduced at a meeting in July 1982. [232] By September 1982 the CDC started referring to the disease as AIDS. [233]

In 1983, two separate research groups led by Robert Gallo and Luc Montagnier declared that a novel retrovirus may have been infecting people with AIDS, and published their findings in the same issue of the journal Science . [234] [235] Gallo claimed that a virus his group had isolated from a person with AIDS was strikingly similar in shape to other human T-lymphotropic viruses (HTLVs) his group had been the first to isolate. Gallo's group called their newly isolated virus HTLV-III. At the same time, Montagnier's group isolated a virus from a person presenting with swelling of the lymph nodes of the neck and physical weakness, two characteristic symptoms of AIDS. Contradicting the report from Gallo's group, Montagnier and his colleagues showed that core proteins of this virus were immunologically different from those of HTLV-I. Montagnier's group named their isolated virus lymphadenopathy-associated virus (LAV). [225] As these two viruses turned out to be the same, in 1986, LAV and HTLV-III were renamed HIV. [236]

Origins

Left to right: the African green monkey source of SIV, the sooty mangabey source of HIV-2 and the chimpanzee source of HIV-1 SIV primates.jpg
Left to right: the African green monkey source of SIV, the sooty mangabey source of HIV-2 and the chimpanzee source of HIV-1

Both HIV-1 and HIV-2 are believed to have originated in non-human primates in West-central Africa and were transferred to humans in the early 20th century. [19] HIV-1 appears to have originated in southern Cameroon through the evolution of SIV(cpz), a simian immunodeficiency virus (SIV) that infects wild chimpanzees (HIV-1 descends from the SIVcpz endemic in the chimpanzee subspecies Pan troglodytes troglodytes). [237] [238] The closest relative of HIV-2 is SIV(smm), a virus of the sooty mangabey (Cercocebus atys atys), an Old World monkey living in coastal West Africa (from southern Senegal to western Côte d'Ivoire). [95] New World monkeys such as the owl monkey are resistant to HIV-1 infection, possibly because of a genomic fusion of two viral resistance genes. [239] HIV-1 is thought to have jumped the species barrier on at least three separate occasions, giving rise to the three groups of the virus, M, N, and O. [240]

There is evidence that humans who participate in bushmeat activities, either as hunters or as bushmeat vendors, commonly acquire SIV. [241] However, SIV is a weak virus which is typically suppressed by the human immune system within weeks of infection. It is thought that several transmissions of the virus from individual to individual in quick succession are necessary to allow it enough time to mutate into HIV. [242] Furthermore, due to its relatively low person-to-person transmission rate, SIV can only spread throughout the population in the presence of one or more high-risk transmission channels, which are thought to have been absent in Africa before the 20th century.

Specific proposed high-risk transmission channels, allowing the virus to adapt to humans and spread throughout the society, depend on the proposed timing of the animal-to-human crossing. Genetic studies of the virus suggest that the most recent common ancestor of the HIV-1 M group dates back to circa 1910. [243] Proponents of this dating link the HIV epidemic with the emergence of colonialism and growth of large colonial African cities, leading to social changes, including a higher degree of sexual promiscuity, the spread of prostitution, and the accompanying high frequency of genital ulcer diseases (such as syphilis) in nascent colonial cities. [244] While transmission rates of HIV during vaginal intercourse are low under regular circumstances, they are increased many fold if one of the partners suffers from a sexually transmitted infection causing genital ulcers. Early 1900s colonial cities were notable due to their high prevalence of prostitution and genital ulcers, to the degree that, as of 1928, as many as 45% of female residents of eastern Kinshasa were thought to have been prostitutes, and, as of 1933, around 15% of all residents of the same city had syphilis. [244]

An alternative view holds that unsafe medical practices in Africa after World War II, such as unsterile reuse of single use syringes during mass vaccination, antibiotic and anti-malaria treatment campaigns, were the initial vector that allowed the virus to adapt to humans and spread. [242] [245] [246]

The earliest well-documented case of HIV in a human dates back to 1959 in the Congo. [247] The earliest retrospectively described case of AIDS is believed to have been in Norway beginning in 1966. [248] In July 1960, in the wake of Congo's independence, the United Nations recruited Francophone experts and technicians from all over the world to assist in filling administrative gaps left by Belgium, who did not leave behind an African elite to run the country. By 1962, Haitians made up the second largest group of well-educated experts (out of the 48 national groups recruited), that totaled around 4500 in the country. [249] [250] Dr. Jacques Pépin, a Quebecer author of The Origins of AIDS, stipulates that Haiti was one of HIV's entry points to the United States and that one of them may have carried HIV back across the Atlantic in the 1960s. [250] Although the virus may have been present in the United States as early as 1966, [251] the vast majority of infections occurring outside sub-Saharan Africa (including the U.S.) can be traced back to a single unknown individual who became infected with HIV in Haiti and then brought the infection to the United States some time around 1969. [252] The epidemic then rapidly spread among high-risk groups (initially, sexually promiscuous men who have sex with men). By 1978, the prevalence of HIV-1 among homosexual male residents of New York City and San Francisco was estimated at 5%, suggesting that several thousand individuals in the country had been infected. [252]

Society and culture

Stigma

Ryan White became a poster child for HIV after being expelled from school because he was infected. Ryan White.jpg
Ryan White became a poster child for HIV after being expelled from school because he was infected.

AIDS stigma exists around the world in a variety of ways, including ostracism, rejection, discrimination and avoidance of HIV infected people; compulsory HIV testing without prior consent or protection of confidentiality; violence against HIV infected individuals or people who are perceived to be infected with HIV; and the quarantine of HIV infected individuals. [21] Stigma-related violence or the fear of violence prevents many people from seeking HIV testing, returning for their results, or securing treatment, possibly turning what could be a manageable chronic illness into a death sentence and perpetuating the spread of HIV. [254]

AIDS stigma has been further divided into the following three categories:

Often, AIDS stigma is expressed in conjunction with one or more other stigmas, particularly those associated with homosexuality, bisexuality, promiscuity, prostitution, and intravenous drug use. [257]

In many developed countries, there is an association between AIDS and homosexuality or bisexuality, and this association is correlated with higher levels of sexual prejudice, such as anti-homosexual/bisexual attitudes. [258] There is also a perceived association between AIDS and all male-male sexual behavior, including sex between uninfected men. [255] However, the dominant mode of spread worldwide for HIV remains heterosexual transmission. [259]

In 2003, as part of an overall reform of marriage and population legislation, it became legal for people with AIDS to marry in China. [260]

In 2013 the U.S. National Library of Medicine developed a traveling exhibition titled, "Surviving and Thriving: AIDS, Politics, and Culture", [261] covering medical research, U.S. government's response, and personal stories from people with AIDS, caregivers, and activists. [262]

Economic impact

Changes in life expectancy in some African countries, 1960-2012 Life expectancy in select Southern African countries 1960-2012.svg
Changes in life expectancy in some African countries, 1960–2012

HIV/AIDS affects the economics of both individuals and countries. [214] The gross domestic product of the most affected countries has decreased due to the lack of human capital. [214] [263] Without proper nutrition, health care and medicine, large numbers of people die from AIDS-related complications. They will not only be unable to work, but will also require significant medical care. It is estimated that as of 2007 there were 12 million AIDS orphans. [214] Many are cared for by elderly grandparents. [264]

Returning to work after beginning treatment for HIV/AIDS is difficult, and affected people often work less than the average worker. Unemployment in people with HIV/AIDS also is associated with suicidal ideation, memory problems, and social isolation. Employment increases self-esteem, sense of dignity, confidence, and quality of life for people with HIV/AIDS. Anti-retroviral treatment may help people with HIV/AIDS work more, and may increase the chance that a person with HIV/AIDS will be employed (low quality evidence). [265]

By affecting mainly young adults, AIDS reduces the taxable population, in turn reducing the resources available for public expenditures such as education and health services not related to AIDS resulting in increasing pressure for the state's finances and slower growth of the economy. This causes a slower growth of the tax base, an effect that is reinforced if there are growing expenditures on treating the sick, training (to replace sick workers), sick pay and caring for AIDS orphans. This is especially true if the sharp increase in adult mortality shifts the responsibility and blame from the family to the government in caring for these orphans. [264]

At the household level, AIDS causes both loss of income and increased spending on healthcare. A study in Côte d'Ivoire showed that households having a person with HIV/AIDS spent twice as much on medical expenses as other households. This additional expenditure also leaves less income to spend on education and other personal or family investment. [266]

Religion and AIDS

The topic of religion and AIDS has become highly controversial in the past twenty years, primarily because some religious authorities have publicly declared their opposition to the use of condoms. [267] [268] The religious approach to prevent the spread of AIDS according to a report by American health expert Matthew Hanley titled The Catholic Church and the Global AIDS Crisis argues that cultural changes are needed including a re-emphasis on fidelity within marriage and sexual abstinence outside of it. [268]

Some religious organizations have claimed that prayer can cure HIV/AIDS. In 2011, the BBC reported that some churches in London were claiming that prayer would cure AIDS, and the Hackney-based Centre for the Study of Sexual Health and HIV reported that several people stopped taking their medication, sometimes on the direct advice of their pastor, leading to a number of deaths. [269] The Synagogue Church Of All Nations advertised an "anointing water" to promote God's healing, although the group denies advising people to stop taking medication. [269]

Media portrayal

One of the first high-profile cases of AIDS was the American Rock Hudson, a gay actor who had been married and divorced earlier in life, who died on October 2, 1985 having announced that he was suffering from the virus on July 25 that year. He had been diagnosed during 1984. [270] A notable British casualty of AIDS that year was Nicholas Eden, a gay politician and son of the late prime minister Anthony Eden. [271] On November 24, 1991, the virus claimed the life of British rock star Freddie Mercury, lead singer of the band Queen, who died from an AIDS-related illness having only revealed the diagnosis on the previous day. [272] However, he had been diagnosed as HIV positive in 1987. [273] One of the first high-profile heterosexual cases of the virus was Arthur Ashe, the American tennis player. He was diagnosed as HIV positive on August 31, 1988, having contracted the virus from blood transfusions during heart surgery earlier in the 1980s. Further tests within 24 hours of the initial diagnosis revealed that Ashe had AIDS, but he did not tell the public about his diagnosis until April 1992. [274] He died as a result on February 6, 1993 at age 49. [275]

Therese Frare's photograph of gay activist David Kirby, as he lay dying from AIDS while surrounded by family, was taken in April 1990. LIFE magazine said the photo became the one image "most powerfully identified with the HIV/AIDS epidemic." The photo was displayed in LIFE magazine, was the winner of the World Press Photo, and acquired worldwide notoriety after being used in a United Colors of Benetton advertising campaign in 1992. [276] In 1996, Johnson Aziga, a Ugandan-born Canadian was diagnosed with HIV, but subsequently had unprotected sex with 11 women without disclosing his diagnosis. By 2003 seven had contracted HIV, and two died from complications related to AIDS. [277] [278] Aziga was convicted of first-degree murder and was sentenced for life. [279]

Criminal transmission

Criminal transmission of HIV is the intentional or reckless infection of a person with the human immunodeficiency virus (HIV). Some countries or jurisdictions, including some areas of the United States, have laws that criminalize HIV transmission or exposure. [280] Others may charge the accused under laws enacted before the HIV pandemic.

Misconceptions

There are many misconceptions about HIV and AIDS. Three of the most common are that AIDS can spread through casual contact, that sexual intercourse with a virgin will cure AIDS, [281] [282] [283] and that HIV can infect only gay men and drug users. In 2014, some among the British public wrongly thought one could get HIV from kissing (16%), sharing a glass (5%), spitting (16%), a public toilet seat (4%), and coughing or sneezing (5%). [284] Other misconceptions are that any act of anal intercourse between two uninfected gay men can lead to HIV infection, and that open discussion of HIV and homosexuality in schools will lead to increased rates of AIDS. [285] [286]

A small group of individuals continue to dispute the connection between HIV and AIDS, [287] the existence of HIV itself, or the validity of HIV testing and treatment methods. [288] [289] These claims, known as AIDS denialism, have been examined and rejected by the scientific community. [290] However, they have had a significant political impact, particularly in South Africa, where the government's official embrace of AIDS denialism (1999–2005) was responsible for its ineffective response to that country's AIDS epidemic, and has been blamed for hundreds of thousands of avoidable deaths and HIV infections. [291] [292] [293]

Several discredited conspiracy theories have held that HIV was created by scientists, either inadvertently or deliberately. Operation INFEKTION was a worldwide Soviet active measures operation to spread the claim that the United States had created HIV/AIDS. Surveys show that a significant number of people believed—and continue to believe—in such claims. [294]

Research

HIV/AIDS research includes all medical research which attempts to prevent, treat, or cure HIV/AIDS along with fundamental research about the nature of HIV as an infectious agent and AIDS as the disease caused by HIV.

Many governments and research institutions participate in HIV/AIDS research. This research includes behavioral health interventions such as sex education, and drug development, such as research into microbicides for sexually transmitted diseases, HIV vaccines, and antiretroviral drugs. Other medical research areas include the topics of pre-exposure prophylaxis, post-exposure prophylaxis, and circumcision and HIV. Public health officials, researchers, and programs can gain a more comprehensive picture of the barriers they face, and the efficacy of current approaches to HIV treatment and prevention, by tracking standard HIV indicators. [295] Use of common indicators is an increasing focus of development organizations and researchers. [296] [297]

Related Research Articles

The Duesberg hypothesis is the claim, associated with University of California, Berkeley professor Peter Duesberg, that various noninfectious factors such as but not limited to, recreational and pharmaceutical drug use are the cause of AIDS, and that HIV is merely a harmless passenger virus. The scientific consensus is that the Duesberg hypothesis is incorrect and that HIV is the cause of AIDS. The most prominent supporters of this hypothesis are Duesberg himself, biochemist vitamin proponent David Rasnick, and journalist Celia Farber. The scientific community contends that Duesberg's arguments are the result of cherry-picking predominantly outdated scientific data and selectively ignoring evidence in favor of HIV's role in AIDS.

The management of HIV/AIDS normally includes the use of multiple antiretroviral drugs in an attempt to control HIV infection. There are several classes of antiretroviral agents that act on different stages of the HIV life-cycle. The use of multiple drugs that act on different viral targets is known as highly active antiretroviral therapy (HAART). HAART decreases the patient's total burden of HIV, maintains function of the immune system, and prevents opportunistic infections that often lead to death.

Male circumcision reduces the risk of HIV transmission from women to men. In 2011, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention if carried out by medical professionals under safe conditions. The United States Centers for Disease Control and Prevention (CDC) states that circumcision reduces the risk that a man will acquire HIV and other sexually transmitted infections (STIs) from an infected female partner.

Opportunistic infection

An opportunistic infection is an infection caused by pathogens that take advantage of an opportunity not normally available, such as a host with a weakened immune system, an altered microbiota, or breached integumentary barriers. Many of these pathogens do not cause disease in a healthy host that has a normal immune system. However, a compromised immune system, which is seriously debilitated and has lowered resistance to infection, a penetrating injury, or a lack of competition from normal commensals presents an opportunity for the pathogen to infect.

Epidemiology of HIV/AIDS

HIV/AIDS is a global pandemic. As of 2017, approximately 36.9 million people are living with HIV globally. In 2018, approximately 43% are women. There were about 940,000 deaths from AIDS in 2017. The 2015 Global Burden of Disease Study, in a report published in The Lancet, estimated that the global incidence of HIV infection peaked in 1997 at 3.3 million per year. Global incidence fell rapidly from 1997 to 2005, to about 2.6 million per year, but remained stable from 2005 to 2015.

The Division of Acquired Immunodeficiency Syndrome (DAIDS) is a division of the National Institute of Allergy and Infectious Diseases which is part of the National Institutes of Health. It was formed in 1986 as a part of the initiative to address the national research needs created by the advent and spread of the HIV/AIDS epidemic. Specifically, the Division’s mission is to increase basic knowledge of the pathogenesis, natural history, and transmission of HIV disease and to support research that promotes progress in its detection, treatment, and prevention. DAIDS accomplishes this through planning, implementing, managing, and evaluating programs in (1) fundamental basic research, (2) discovery and development of therapies for HIV infection and its complications, and (3) discovery and development of vaccines and other prevention strategies.

HIV superinfection is a condition in which a person with an established human immunodeficiency virus infection acquires a second strain of HIV, often of a different subtype. These can form a recombinant strain that co-exists with the strain from the initial infection, as well as the strain from the new virus, and may cause more rapid disease progression or carry multiple resistances to certain HIV medications.

Sexually transmitted infection Infection transmitted through human sexual behavior

Sexually transmitted infections (STI), also referred to as sexually transmitted diseases (STD), are infections that are commonly spread by sexual activity, especially vaginal intercourse, anal sex and oral sex. Many times STIs initially do not cause symptoms. This results in a greater risk of passing the disease on to others. Symptoms and signs of disease may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. STIs can be transmitted to an infant before or during childbirth and may result in poor outcomes for the baby. Some STIs may cause problems with the ability to get pregnant.

HIV/AIDS in Haiti

With an estimated 150,000 people living with HIV/AIDS in 2016, Haiti has the most overall cases of HIV/AIDS in the Caribbean and its HIV prevalence rates among the highest percentage-wise in the region. There are many risk factors groups for HIV infection in Haiti, with the most common ones including lower socioeconomic status, lower educational levels, risky behavior, and lower levels of awareness regarding HIV and its transmission. However, HIV prevalence in Haiti is largely dropping as a result of a strong AIDS/HIV educational program, support from non-governmental organizations and private donors, as well as a strong healthcare system supported by UNAIDS. Part of the success of Haiti's HIV healthcare system lies in the governmental commitment to the issue, which alongside the support of donations from the Global Fund and President's Emergency Plan For AIDS Relief (PEPFAR), allows the nation to prioritize the issue. Despite the extreme poverty afflicting a large Haitian population, the severe economic impact HIV has on the nation, and the controversy surrounding how the virus spread to Haiti and the United States, Haiti is on the path to provide universal treatment, with other developing nations emulating its AIDS treatment system.

Prevention of HIV/AIDS prevent and minimize the occurrence of HIV and AIDS

HIV prevention might refer to practices done to prevent the spread of HIV/AIDS. HIV prevention practices may be done by individuals to protect "their own health" and the health of those in their community, or may be instituted by governments or other organizations as "public health policies".

The stages of HIV infection are acute infection, latency and AIDS. Acute infection lasts for several weeks and may include symptoms such as fever, swollen lymph nodes, inflammation of the throat, rash, muscle pain, malaise, and mouth and esophageal sores. The latency stage involves few or no symptoms and can last anywhere from two weeks to twenty years or more, depending on the individual. AIDS, the final stage of HIV infection, is defined by low CD4+ T cell counts, various opportunistic infections, cancers and other conditions.

The co-epidemic of tuberculosis (TB) and human immunodeficiency virus (HIV) is one of the major global health challenges in the present time. The World Health Organization (WHO) reports 9.2 million new cases of TB in 2006 of whom 7.7% were HIV-infected. Tuberculosis is the most common contagious infection in HIV-Immunocompromised patients leading to death. These both diseases become dreadful in combination as HIV declines the human immunity while tuberculosis becomes progressive due to defective immune system.This condition becomes more severe in case of multi-drug (MDRTB) and extensively drug resistant TB (XDRTB), which are difficult to treat and contribute to increased mortality. See Multi-drug-resistant tuberculosis. Tuberculosis can occur at any stage of HIV infection. The risk and severity of tuberculosis increases soon after infection with HIV. A study on gold miners of South Africa revealed that the risk of TB was doubled during the first year after HIV seroconversion. Although tuberculosis can be a relatively early manifestation of HIV infection, it is important to note that the risk of tuberculosis progresses as the CD4 cell count decreases along with the progression of HIV infection. The risk of TB generally remains high in HIV-infected patients above the background risk of the general population even with effective immune reconstitution with ART maintaining high CD4 cell counts.

Myron Scott Cohen is an American physician-scientist who has made substantial contributions to our understanding of the transmission prevention of transmission of HIV. He is best known as chief architect of HIV Prevention Trials Network 052, a large-scale randomized clinical trial which demonstrated proof-of-concept for “treatment as prevention”: treating an HIV-infected person with antiviral drugs makes them less contagious and prevents transmission to their sexual partners. Cohen is J. Herbert Bate Distinguished Professor of Medicine, Microbiology and Immunology, and Epidemiology at the University of North Carolina at Chapel Hill. He is also co-chair of the National Institutes of Health's HIV Prevention Trials Network.

HIV in pregnancy is the presence of HIV in a woman while she is pregnant. HIV in pregnancy is of concern because women with HIV/AIDS may transmit the infection to their child during pregnancy, childbirth and while breastfeeding. However, the risk of mother-to-child transmission of HIV may be reduced by treatment of the HIV infection with antiretroviral therapy (ART). This lifelong therapy may be initiated in women before, during, and after pregnancy. After delivery, children are also given the medication temporarily as a prophylactic measure to reduce the risk of infection. Because HIV may also be spread through breast milk, mothers in the United States who are infected are encouraged to avoid breastfeeding. However, in developing countries such as South Africa, where the risk of death of the infant associated with avoiding exclusive breastfeeding is higher than the risk of contracting HIV, exclusive breastfeeding in a mother who is virally suppressed is encouraged.

A small proportion of humans show partial or apparently complete inborn resistance to HIV, the virus that causes AIDS. The main mechanism is a mutation of the gene encoding CCR5, which acts as a co-receptor for HIV. It is estimated that the proportion of people with some form of resistance to HIV is under 1%.

Treatment as prevention (TasP) is a concept in public health that promotes treatment as a way to prevent and reduce the likelihood of the transmission of an infection from an infected individual to others. The term is primarily used to talk about treating people that are currently living with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) to lower the risk of new HIV infection transmissions. In relation to HIV, antiretroviral therapy (ART) is a three or more drug combination therapy that is used to decrease the viral load, or the measured amount of virus, in an infected individual. Such medications are used as a preventative for infected individuals to not only spread the HIV virus to their negative partners but also improve their current health to increase their lifespans. Other names for ART include highly active antiretroviral therapy (HAART), combination antiretroviral therapy (cART), triple therapy and triple drug cocktail. When taken correctly, ARVs are able to diminish the presence of the HIV virus in the bodily fluids of an infected person to a level of undetectability. Undetectability ensures that infection does not necessarily have an effect on a person's general health, and that there is no longer a risk of passing along HIV to others. Consistent adherence to an ARV regimen, monitoring, and testing are essential for continued confirmed viral suppression. Treatment as prevention rose to great prominence in 2011, as part of the HPTN 052 study, which shed light on the benefits of early treatment for HIV positive individuals.

Viral load monitoring for HIV is the regular measurement of the viral load of individual HIV-positive people as part of their personal plan for treatment of HIV/AIDS. A count of the viral load is routine before the start of HIV treatment.

Sharon Lewin

Sharon Ruth Lewin, FRACP, FAHMS is an Australian Infectious Disease physician and researcher, and the inaugural director of The Peter Doherty Institute for Infection and Immunity, a joint venture between the University of Melbourne and the Royal Melbourne Hospital. She leads a multi-disciplinary research team working on mechanisms of HIV latency, clinical trials advancing potential HIV cure strategies and how HIV is affected by co-infections such as Hepatitis B. Lewin has extensive experience in scientific leadership, and is a strong advocate for community engagement and partnership in research.

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