AIDS

Acquired immune deficiency syndrome or acquired immunodeficiency

syndrome (AIDS or Aids) is a set of symptoms and infections resulting
from the damage to the human immune system caused by the human
immunodeficiency virus (HIV).
[1]
This condition progressively reduces the
effectiveness of the immune system and leaves individuals susceptible to
opportunistic infections and tumors. HIV is transmitted through direct
contact of a mucous membrane or the bloodstream ith a bodily fluid
containing HIV! such as blood! semen! vaginal fluid! preseminal fluid! and
breast mil".
[#][$]
This transmission can involve anal! vaginal or oral se%!
blood transfusion! contaminated hypodermic needles! e%change beteen
mother and baby during pregnancy! childbirth! or breastfeeding! or other
e%posure to one of the above bodily fluids.
&I'( is no a pandemic.
[)]
In #**+! an estimated $$.# million people lived
ith the disease orldide! and it "illed an estimated #.1 million people!
including $$*!*** children.
[,]
-ver three./uarters of these deaths occurred in
sub.(aharan &frica!
[,]
retarding economic groth and destroying human
capital.
[0]
1ost researchers believe that HIV originated in sub.(aharan
&frica during the tentieth century.
[+]
&I'( as first recogni2ed by the 3.(.
4enters for 'isease 4ontrol and 5revention in 1671 and its cause! HIV!
identified by &merican and 8rench scientists in the early 167*s.
[7]
&lthough treatments for &I'( and HIV can slo the course of the disease!
there is currently no vaccine or cure. &ntiretroviral treatment reduces both
the mortality and the morbidity of HIV infection! but these drugs are
e%pensive and routine access to antiretroviral medication is not available in
all countries.
[6]
'ue to the difficulty in treating HIV infection! preventing
infection is a "ey aim in controlling the &I'( epidemic! ith health
organi2ations promoting safe se% and needle.e%change programmes in
attempts to slo the spread of the virus.
History
&I'( as first reported 9une ,! 1671! hen the 3.(. 4enters for 'isease
4ontrol and 5revention recorded a cluster of Pneumocystis carinii
pneumonia (no still classified as 545 but "non to be caused by
Pneumocystis jirovecii) in five homose%ual men in :os &ngeles.
[1#0]
In the
beginning! the 4enters for 'isease 4ontrol and 5revention (4'4) did not
have an official name for the disease! often referring to it by ay of the
diseases that ere associated ith it! for e%ample! lymphadenopathy! the
disease after hich the discoverers of HIV originally named the virus.
[00][0+]
They also used Kaposi's Sarcoma and Opportunistic Infections! the name by
hich a tas" force had been set up in 1671.
[1#+]
In the general press! the term
GRID! hich stood for ;ay.related immune deficiency! had been coined.
[1#7]
The 4'4! in search of a name! and loo"ing at the infected communities
coined <the )H disease!= as it seemed to single out Haitians! homose%uals!
hemophiliacs! and heroin users.
[1#6]
Hoever! after determining that &I'(
as not isolated to the homose%ual community!
[1#+]
the term ;>I' became
misleading and AIDS as introduced at a meeting in 9uly 167#.
[1$*]
?y
(eptember 167# the 4'4 started using the name &I'(! and properly
defined the illness.
[1$1]
& more controversial theory "non as the -5V &I'( hypothesis suggests
that the &I'( epidemic as inadvertently started in the late 16,*s in the
?elgian 4ongo by Hilary @opros"iAs research into a poliomyelitis vaccine.
[1$#][1$$]
&ccording to scientific consensus! this scenario is not supported by
the available evidence.
[1$)][1$,][1$0]
& recent study states that HIV probably moved from &frica to Haiti and then
entered the 3nited (tates around 1606.
[1$+]
Contents
1 History
# 4ause
o #.1 (e%ual transmission
o #.# 5erinatal transmission
o #.$ 1isconceptions
$ 5athophysiology
o $.1 4ells affected
o $.# The effect
o $.$ 1olecular basis
) 'iagnosis
o ).1 BH- disease staging system
o ).# HIV test
, 5revention
o ,.1 (e%ual contact
o ,.# C%posure to infected body fluids
o ,.$ 1other.to.child transmission (1T4T)
0 Treatment
o 0.1 &lternative medicine
+ Cpidemiology
7 5rognosis
6 (ociety and culture
o 6.1 &I'( denialism

Symptoms
& generali2ed graph of the relationship beteen HIV copies (viral
load) and 4') counts over the average course of untreated HIV infectionD
any particular individualAs disease course may vary considerably. 4')
E
T
:ymphocyte count (cellsFmmG) HIV >H& copies per m: of plasma
The symptoms of &I'( are primarily the result of conditions that do
not normally develop in individuals ith healthy immune systems. 1ost of
these conditions are infections caused by bacteria! viruses! fungi and
parasites that are normally controlled by the elements of the immune system
that HIV damages. -pportunistic infections are common in people ith
&I'(.
[1*]
HIV affects nearly every organ system. 5eople ith &I'( also
have an increased ris" of developing various cancers such as @aposiAs
sarcoma! cervical cancer and cancers of the immune system "non as
lymphomas. &dditionally! people ith &I'( often have systemic symptoms
of infection li"e fevers! seats (particularly at night)! sollen glands! chills!
ea"ness! and eight loss.
[11][1#]
The specific opportunistic infections that
&I'( patients develop depend in part on the prevalence of these infections
in the geographic area in hich the patient lives.
Gastrointestinal infections
Csophagitis is an inflammation of the lining of the loer end of the
esophagus (gullet or salloing tube leading to the stomach). In HIV
infected individuals! this is normally due to fungal (candidiasis) or viral
(herpes simple%.1 or cytomegalovirus) infections. In rare cases! it could be
due to mycobacteria.
[1,]
3ne%plained chronic diarrhea in HIV infection is due to many possible
causes! including common bacterial (Salmonella! Shigella! isteria or
!ampylo"acter) and parasitic infectionsD and uncommon opportunistic
infections such as cryptosporidiosis! microsporidiosis! #yco"acterium
avium comple% (1&4) and viruses!
[10]
astrovirus! adenovirus! rotavirus and
cytomegalovirus! (the latter as a course of colitis). In some cases! diarrhea
may be a side effect of several drugs used to treat HIV! or it may simply
accompany HIV infection! particularly during primary HIV infection. It may
also be a side effect of antibiotics used to treat bacterial causes of diarrhea
(common for !lostridium difficile). In the later stages of HIV infection!
diarrhea is thought to be a reflection of changes in the ay the intestinal
tract absorbs nutrients! and may be an important component of HIV.related
asting.
[1+]
Other opportunistic infections
&I'( patients often develop opportunistic infections that present ith non.
specific symptoms! especially lo.grade fevers and eight loss. These
include infection ith #yco"acterium avium$intracellulare and
cytomegalovirus (41V). 41V can cause colitis! as described above! and
41V retinitis can cause blindness. 5enicilliosis due to Penicillium
marneffei is no the third most common opportunistic infection (after
e%trapulmonary tuberculosis and cryptococcosis) in HIV.positive
individuals ithin the endemic area of (outheast &sia.
[#7]
Cause
(canning electron micrograph of HIV.1! colored green! budding from a
cultured lymphocyte.
&I'( is the most severe acceleration of infection ith HIV. HIV is a
retrovirus that primarily infects vital organs of the human immune system
such as 4')
E
T cells (a subset of T cells)! macrophages and dendritic cells.
It directly and indirectly destroys 4')
E
T cells.
[#6]
-nce HIV has "illed so
many 4')
E
T cells that there are feer than #** of these cells per microliter
(I:) of blood! cellular immunity is lost. &cute HIV infection progresses
over time to clinical latent HIV infection and then to early symptomatic HIV
infection and later to &I'(! hich is identified either on the basis of the
amount of 4')
E
T cells remaining in the blood! andFor the presence of
certain infections! as noted above.
[$*]
In the absence of antiretroviral therapy! the median time of progression from
HIV infection to &I'( is nine to ten years! and the median survival time
after developing &I'( is only 6.# months.
[$1]
Hoever! the rate of clinical
disease progression varies idely beteen individuals! from to ee"s up
to #* years. 1any factors affect the rate of progression. These include
factors that influence the bodyAs ability to defend against HIV such as the
infected personAs general immune function.
[$#][$$]
-lder people have ea"er
immune systems! and therefore have a greater ris" of rapid disease
progression than younger people. 5oor access to health care and the
e%istence of coe%isting infections such as tuberculosis also may predispose
people to faster disease progression.
[$1][$)][$,]
The infected personAs genetic
inheritance plays an important role and some people are resistant to certain
strains of HIV. &n e%ample of this is people ith the homo2ygous 44>,.
J$# variation are resistant to infection ith certain strains of HIV.
[$0]
HIV is
genetically variable and e%ists as different strains! hich cause different
rates of clinical disease progression.
[$+][$7][$6]
Sexual transmission
(e%ual transmission occurs ith the contact beteen se%ual secretions of
one person ith the rectal! genital or oral mucous membranes of another.
3nprotected receptive se%ual acts are ris"ier than unprotected insertive
se%ual acts! and the ris" for transmitting HIV through unprotected anal
intercourse is greater than the ris" from vaginal intercourse or oral se%.
Hoever! oral se% is not entirely safe! as HIV can be transmitted through
both insertive and receptive oral se%.
[)*][)1]
(e%ual assault greatly increases
the ris" of HIV transmission as protection is rarely employed and physical
trauma to the vagina fre/uently occurs! facilitating the transmission of HIV.
[)#]
-ther se%ually transmitted infections ((TI) increase the ris" of HIV
transmission and infection! because they cause the disruption of the normal
epithelial barrier by genital ulceration andFor microulcerationD and by
accumulation of pools of HIV.susceptible or HIV.infected cells
(lymphocytes and macrophages) in semen and vaginal secretions.
Cpidemiological studies from sub.(aharan &frica! Curope and Horth
&merica suggest that genital ulcers! such as those caused by syphilis andFor
chancroid! increase the ris" of becoming infected ith HIV by about four.
fold. There is also a significant although lesser increase in ris" from (TIs
such as gonorrhea! 4hlamydial infection and trichomoniasis! hich all cause
local accumulations of lymphocytes and macrophages.
[)$]
Transmission of HIV depends on the infectiousness of the inde% case and the
susceptibility of the uninfected partner. Infectivity seems to vary during the
course of illness and is not constant beteen individuals. &n undetectable
plasma viral load does not necessarily indicate a lo viral load in the
seminal li/uid or genital secretions. Hoever! each 1*.fold increase in the
level of HIV in the blood is associated ith an 71K increased rate of HIV
transmission.
[)$][))]
Bomen are more susceptible to HIV.1 infection due to
hormonal changes! vaginal microbial ecology and physiology! and a higher
prevalence of se%ually transmitted diseases.
[),][)0]
5eople ho have been
infected ith one strain of HIV can still be infected later on in their lives by
other! more virulent strains.
Infection is unli"ely in a single encounter. High rates of infection have been
lin"ed to a pattern of overlapping long.term romantic relationships. This
allos the virus to /uic"ly spread to multiple partners ho in turn infect
their partners. & pattern of serial monogamy or occasional casual encounters
is associated ith loer rates of infection.
[)+]
HIV spreads readily through heterose%ual se% in &frica! but less so
elsehere. -ne possibility being researched is that schistosomiasis! hich
affects up to ,* per cent of omen in parts of &frica! damages the lining of
the vagina.
[)7][)6]
Perinatal transmission
The transmission of the virus from the mother to the child can occur in utero
during the last ee"s of pregnancy and at childbirth. In the absence of
treatment! the transmission rate beteen a mother and her child during
pregnancy! labor and delivery is #,K. Hoever! hen the mother ta"es
antiretroviral therapy and gives birth by caesarean section! the rate of
transmission is Lust 1K.
[,)]
The ris" of infection is influenced by the viral
load of the mother at birth! ith the higher the viral load! the higher the ris".
?reastfeeding also increases the ris" of transmission by about ) K.
[,,]
Misconceptions
& number of misconceptions have arisen surrounding HIVF&I'(. Three of
the most common are that &I'( can spread through casual contact! that
se%ual intercourse ith a virgin ill cure &I'(! and that HIV can infect
only homose%ual men and drug users. -ther misconceptions are that any act
of anal intercourse beteen gay men can lead to &I'( infection! and that
open discussion of homose%uality and HIV in schools ill lead to increased
rates of homose%uality and &I'(.
[,0]
Pathophysiology
The pathophysiology of &I'( is comple%! as is the case ith all syndromes.
[,+]
3ltimately! HIV causes &I'( by depleting 4')
E
T helper lymphocytes.
This ea"ens the immune system and allos opportunistic infections. T
lymphocytes are essential to the immune response and ithout them! the
body cannot fight infections or "ill cancerous cells. The mechanism of 4')
E
T cell depletion differs in the acute and chronic phases.
[,7]
'uring the acute
phase! HIV.induced cell lysis and "illing of infected cells by cytoto%ic T
cells accounts for 4')
E
T cell depletion! although apoptosis may also be a
factor. 'uring the chronic phase! the conse/uences of generali2ed immune
activation coupled ith the gradual loss of the ability of the immune system
to generate ne T cells appear to account for the slo decline in 4')
E
T cell
numbers.
&lthough the symptoms of immune deficiency characteristic of &I'( do not
appear for years after a person is infected! the bul" of 4')
E
T cell loss
occurs during the first ee"s of infection! especially in the intestinal
mucosa! hich harbors the maLority of the lymphocytes found in the body.
[,6]
The reason for the preferential loss of mucosal 4')
E
T cells is that a
maLority of mucosal 4')
E
T cells e%press the 44>, coreceptor! hereas a
small fraction of 4')
E
T cells in the bloodstream do so.
[0*]
HIV see"s out
and destroys 44>, e%pressing 4')
E
cells during acute infection. & vigorous
immune response eventually controls the infection and initiates the clinically
latent phase. Hoever! 4')
E
T cells in mucosal tissues remain depleted
throughout the infection! although enough remain to initially ard off life.
threatening infections.
4ontinuous HIV replication results in a state of generali2ed immune
activation persisting throughout the chronic phase.
[01]
Immune activation!
hich is reflected by the increased activation state of immune cells and
release of proinflammatory cyto"ines! results from the activity of several
HIV gene products and the immune response to ongoing HIV replication.
&nother cause is the brea"don of the immune surveillance system of the
mucosal barrier caused by the depletion of mucosal 4')
E
T cells during the
acute phase of disease.
[0#]
This results in the systemic e%posure of the
immune system to microbial components of the gutMs normal flora! hich in
a healthy person is "ept in chec" by the mucosal immune system. The
activation and proliferation of T cells that results from immune activation
provides fresh targets for HIV infection. Hoever! direct "illing by HIV
alone cannot account for the observed depletion of 4')
E
T cells since only
*.*1.*.1*K of 4')
E
T cells in the blood are infected. & maLor cause of
4')
E
T cell loss appears to result from their heightened susceptibility to
apoptosis hen the immune system remains activated. &lthough ne T cells
are continuously produced by the thymus to replace the ones lost! the
regenerative capacity of the thymus is sloly destroyed by direct infection
of its thymocytes by HIV. Cventually! the minimal number of 4')
E
T cells
necessary to maintain a sufficient immune response is lost! leading to &I'(
Cells affected
The virus! entering through hich ever route! acts primarily on the folloing
cellsN
[0$]
1. :ymphoreticular system N
1. 4'
)
E T.Helper cells
#. 4'
)
E 1acrophages
$. 4'
)
E 1onocytes
). ?.lymphocytes
#. 4ertain endothelial cells
$. 4entral nervous system N
1. 1icroglia of the nervous system
#. &strocytes
$. -ligodendrocytes
). Heurones . indirectly by the action of cyto"ines and the gp.1#*
he effect
The virus has cytopathic effects but ho it does it is still not /uite clear. It
can remain inactive in these cells for long periods! though. This effect is
hypothesi2ed to be due to the 4'
)
.gp1#* interaction.
[0)]
The most prominent effect of the HIV virus is its T.helper cell
suppression and lysis. The cell is simply "illed off or deranged to the
point of being function.less (they do not respond to foreign antigens).
The infected ?.cells can not produce enough antibodies either. Thus
the immune system collapses leading to the familiar &I'(
complications! li"e infections and neoplasms (vide supra).
Infection of the cells of the 4H( cause acute aseptic meningitis!
subacute encephalitis! vacuolar myelopathy and peripheral
neuropathy. :ater it leads to even &I'( dementia comple%.
The 4'
)
.gp1#* interaction (vide supra) is also permissive to other
viruses li"e 4ytomegalovirus! Hepatitis virus! Herpes simple% virus!
etc. These viruses lead to further cell damage i.e. cytopathy.
Molecular !asis
(tructure and genome of HIV
HIV replication cycle
HIV tropism
Diagnosis
The diagnosis of &I'( in a person infected ith HIV is based on the
presence of certain signs or symptoms. (ince 9une ,! 1671! many definitions
have been developed for epidemiological surveillance such as the ?angui
definition and the 166) e%panded Borld Health -rgani2ation &I'( case
definition. Hoever! clinical staging of patients as not an intended use for
these systems as they are neither sensitive! nor specific. In developing
countries! the Borld Health -rgani2ation staging system for HIV infection
and disease! using clinical and laboratory data! is used and in developed
countries! the 4enters for 'isease 4ontrol (4'4) 4lassification (ystem is
used.
"HO disease staging system
In 166*! the Borld Health -rgani2ation (BH-) grouped these infections
and conditions together by introducing a staging system for patients infected
ith HIV.1.
[0,]
&n update too" place in (eptember #**,. 1ost of these
conditions are opportunistic infections that are easily treatable in healthy
people.
(tage IN HIV infection is asymptomatic and not categori2ed as &I'(
(tage IIN includes minor mucocutaneous manifestations and recurrent
upper respiratory tract infections
(tage IIIN includes une%plained chronic diarrhea for longer than a
month! severe bacterial infections and pulmonary tuberculosis
(tage IVN includes to%oplasmosis of the brain! candidiasis of the
esophagus! trachea! bronchi or lungs and @aposiAs sarcomaD these
diseases are indicators of &I'(.
HI# test
1any people are unaare that they are infected ith HIV.
[06]
:ess than 1K
of the se%ually active urban population in &frica has been tested! and this
proportion is even loer in rural populations. 8urthermore! only *.,K of
pregnant omen attending urban health facilities are counseled! tested or
receive their test results. &gain! this proportion is even loer in rural health
facilities.
[06]
Therefore! donor blood and blood products used in medicine and
medical research are screened for HIV.
HIV tests are usually performed on venous blood. 1any laboratories use
fourth generation screening tests hich detect anti.HIV antibody (Ig; and
Ig1) and the HIV p#) antigen. The detection of HIV antibody or antigen in
a patient previously "non to be negative is evidence of HIV infection.
Individuals hose first specimen indicates evidence of HIV infection ill
have a repeat test on a second blood sample to confirm the results. The
indo period (the time beteen initial infection and the development of
detectable antibodies against the infection) can vary since it can ta"e $O
0 months to seroconvert and to test positive. 'etection of the virus using
polymerase chain reaction (54>) during the indo period is possible! and
evidence suggests that an infection may often be detected earlier than hen
using a fourth generation CI& screening test. 5ositive results obtained by
54> are confirmed by antibody tests.
[+*]
>outinely used HIV tests for
infection in neonates! born to HIV.positive mothers! have no value because
of the presence of maternal antibody to HIV in the childAs blood. HIV
infection can only be diagnosed by 54>! testing for HIV pro.viral 'H& in
the childrenAs lymphocytes.
[+1]
Pre$ention
%xposure &oute
%stimated infections
per '()((( exposures
to an infected source
*lood ransfusion 6!***
[+$]
Child!irth #!,**
[,)]
+eedle,sharing in-ection drug use 0+
[+)]
Percutaneous needle stic. $*
[+,]
&ecepti$e anal intercourse
/
,*
[+0][++]
Inserti$e anal intercourse
/
0.,
[+0][++]
&ecepti$e penile,$aginal intercourse
/
1*
[+0][++][+7]
Inserti$e penile,$aginal intercourse
/
,
[+0][++]
&ecepti$e oral intercourse
/0
1
[++]
Inserti$e oral intercourse
/
*.,
[++]P
The three main transmission routes of HIV are se%ual contact! e%posure to
infected body fluids or tissues! and from mother to fetus or child during
perinatal period. It is possible to find HIV in the saliva! tears! and urine of
infected individuals! but there are no recorded cases of infection by these
secretions! and the ris" of infection is negligible.
[+6]
Sexual contact
The maLority of HIV infections are ac/uired through unprotected se%ual
relations beteen partners! one of hom has HIV. The primary mode of
HIV infection orldide is through se%ual contact beteen members of the
opposite se%.
[7*][71][7#]
'uring a se%ual act! only male or female condoms can
reduce the chances of infection ith HIV and other (T's and the chances of
becoming pregnant. The best evidence to date indicates that typical condom
use reduces the ris" of heterose%ual HIV transmission by appro%imately
7*K over the long.term! though the benefit is li"ely to be higher if condoms
are used correctly on every occasion.
[7$]
The male late% condom! if used
correctly ithout oil.based lubricants! is the single most effective available
technology to reduce the se%ual transmission of HIV and other se%ually
transmitted infections. 1anufacturers recommend that oil.based lubricants
such as petroleum Lelly! butter! and lard not be used ith late% condoms!
because they dissolve the late%! ma"ing the condoms porous. If necessary!
manufacturers recommend using ater.based lubricants. -il.based
lubricants can hoever be used ith polyurethane condoms.
[7)]
The female condom is an alternative to the male condom and is made from
polyurethane! hich allos it to be used in the presence of oil.based
lubricants. They are larger than male condoms and have a stiffened ring.
shaped opening! and are designed to be inserted into the vagina. The female
condom contains an inner ring! hich "eeps the condom in place inside the
vagina O inserting the female condom re/uires s/uee2ing this ring. Hoever!
at present availability of female condoms is very lo and the price remains
prohibitive for many omen. 5reliminary studies suggest that! here female
condoms are available! overall protected se%ual acts increase relative to
unprotected se%ual acts! ma"ing them an important HIV prevention strategy.
[7,]
(tudies on couples here one partner is infected sho that ith consistent
condom use! HIV infection rates for the uninfected partner are belo 1K per
year.
[70]
5revention strategies are ell."non in developed countries!
hoever! recent epidemiological and behavioral studies in Curope and Horth
&merica have suggested that a substantial minority of young people
continue to engage in high.ris" practices and that despite HIVF&I'(
"noledge! young people underestimate their on ris" of becoming infected
ith HIV.
[7+]
>andomi2ed controlled trials have shon that male circumcision loers the
ris" of HIV infection among heterose%ual men by up to 0*K.
[77]
It is
e%pected that this procedure ill be actively promoted in many of the
countries affected by HIV! although doing so ill involve confronting a
number of practical! cultural and attitudinal issues. (ome e%perts fear that a
loer perception of vulnerability among circumcised men may result in
more se%ual ris".ta"ing behavior! thus negating its preventive effects.
[76]
%xposure to infected !ody fluids
Health care or"ers can reduce e%posure to HIV by employing precautions
to reduce the ris" of e%posure to contaminated blood. These precautions
include barriers such as gloves! mas"s! protective eyeare or shields! and
gons or aprons hich prevent e%posure of the s"in or mucous membranes
to blood borne pathogens. 8re/uent and thorough ashing of the s"in
immediately after being contaminated ith blood or other bodily fluids can
reduce the chance of infection. 8inally! sharp obLects li"e needles! scalpels
and glass! are carefully disposed of to prevent needlestic" inLuries ith
contaminated items.
[6*]
(ince intravenous drug use is an important factor in
HIV transmission in developed countries! harm reduction strategies such as
needle.e%change programmes are used in attempts to reduce the infections
caused by drug abuse.
[61][6#]
Mother,to,child transmission 1MC2
4urrent recommendations state that hen replacement feeding is acceptable!
feasible! affordable! sustainable and safe! HIV.infected mothers should
avoid breast.feeding their infant. Hoever! if this is not the case! e%clusive
breast.feeding is recommended during the first months of life and
discontinued as soon as possible.
[6$]
reatment
The chemical structure of &bacavir
There is currently no vaccine or cure for HIV or &I'(. The only "non
methods of prevention are based on avoiding e%posure to the virus or! failing
that! an antiretroviral treatment directly after a highly significant e%posure!
called post.e%posure prophyla%is (5C5).
[6)]
5C5 has a very demanding four
ee" schedule of dosage. It also has very unpleasant side effects including
diarrhea! malaise! nausea and fatigue.
[6,]
Anti$iral therapy
4urrent treatment for HIV infection consists of highly active antiretroviral
therapy! or H&&>T.
[60]
This has been highly beneficial to many HIV.
infected individuals since its introduction in 1660 hen the protease
inhibitor.based H&&>T initially became available.
[6]
4urrent optimal
H&&>T options consist of combinations (or Qcoc"tailsQ) consisting of at
least three drugs belonging to at least to types! or Qclasses!Q of
antiretroviral agents. Typical regimens consist of to nucleoside analogue
reverse transcriptase inhibitors (H&>TIs or H>TIs) plus either a protease
inhibitor or a non.nucleoside reverse transcriptase inhibitor (HH>TI).
?ecause HIV disease progression in children is more rapid than in adults!
and laboratory parameters are less predictive of ris" for disease progression!
particularly for young infants! treatment recommendations are more
aggressive for children than for adults.
[6+]
In developed countries here
H&&>T is available! doctors assess the viral load! rapidity in 4') decline!
and patient readiness hile deciding hen to recommend initiating
treatment.
[67]
H&&>T allos the stabili2ation of the patientMs symptoms and viremia! but
it neither cures the patient of HIV! nor alleviates the symptoms! and high
levels of HIV.1! often H&&>T resistant! return once treatment is stopped.
[66]
[1**]
1oreover! it ould ta"e more than the lifetime of an individual to be
cleared of HIV infection using H&&>T.
[1*1]
'espite this! many HIV.infected
individuals have e%perienced remar"able improvements in their general
health and /uality of life! hich has led to the plummeting of HIV.
associated morbidity and mortality.
[1*#][1*$][1*)]
In the absence of H&&>T!
progression from HIV infection to &I'( occurs at a median of beteen nine
to ten years and the median survival time after developing &I'( is only
6.# months.
[$1]
H&&>T is thought to increase survival time by beteen )
and 1# years.
[1*,][1*0]
8or some patients! hich can be more than fifty percent of patients! H&&>T
achieves far less than optimal results! due to medication intoleranceFside
effects! prior ineffective antiretroviral therapy and infection ith a drug.
resistant strain of HIV. Hon.adherence and non.persistence ith therapy are
the maLor reasons hy some people do not benefit from H&&>T.
[1*+]
The
reasons for non.adherence and non.persistence are varied. 1aLor
psychosocial issues include poor access to medical care! inade/uate social
supports! psychiatric disease and drug abuse. H&&>T regimens can also be
comple% and thus hard to follo! ith large numbers of pills ta"en
fre/uently.
[1*7][1*6][11*]
(ide effects can also deter people from persisting ith
H&&>T! these include lipodystrophy! dyslipidaemia! diarrhoea! insulin
resistance! an increase in cardiovascular ris"s and birth defects.
[111]
&nti.
retroviral drugs are e%pensive! and the maLority of the orldAs infected
individuals do not have access to medications and treatments for HIV and
&I'(.
3uture research
It has been postulated that only a vaccine can halt the pandemic because a
vaccine ould possibly cost less! thus being affordable for developing
countries! and ould not re/uire daily treatments. Hoever! even after
almost $* years of research! HIV.1 remains a difficult target for a vaccine.
[11#]
>esearch to improve current treatments includes decreasing side effects of
current drugs! further simplifying drug regimens to improve adherence! and
determining the best se/uence of regimens to manage drug resistance. &
number of studies have shon that measures to prevent opportunistic
infections can be beneficial hen treating patients ith HIV infection or
&I'(. Vaccination against hepatitis & and ? is advised for patients ho are
not infected ith these viruses and are at ris" of becoming infected.
[11$]
5atients ith substantial immunosuppression are also advised to receive
prophylactic therapy for 5neumocystis Liroveci pneumonia (545)! and many
patients may benefit from prophylactic therapy for to%oplasmosis and
4ryptococcus meningitis as ell.
[6,]
>esearchers have discovered an ab2yme that can destroy the protein gp1#*
4') binding site. This protein is common to all HIV variants as it is the
attachment point for ? lymphocytes and subse/uent compromising of the
immune system.
[11)]
Alternati$e medicine
Various forms of alternative medicine have been used to treat symptoms or
alter the course of the disease.
[11,]
&cupuncture has been used to alleviate
some symptoms! such peripheral neuropathy! but cannot cure the HIV
infection.
[110]
(everal randomi2ed clinical trials testing the effect of herbal
medicines have shon that there is no evidence that these herbs have any
effect on the progression of the disease! but may instead produce serious
side.effects.
[11+]
(ome data suggest that multivitamin and mineral supplements might reduce
HIV disease progression in adults! although there is no conclusive evidence
on if they reduce mortality among people ith good nutritional status.
[117]
Vitamin & supplementation in children probably has some benefit.
[117]
'aily
doses of selenium can suppress HIV viral burden ith an associated
improvement of the 4') count. (elenium can be used as an adLunct therapy
to standard antiviral treatments! but cannot itself reduce mortality and
morbidity.
[116]
4urrent studies indicate that that alternative medicine therapies have little
effect on the mortality or morbidity of the disease! but may improve the
/uality of life of individuals afflicted ith &I'(. The psychological benefits
of these therapies are the most important use.
[11,]
Prognosis
Bithout treatment! the net median survival time after infection ith HIV is
estimated to be 6 to 11 years! depending on the HIV subtype!
[,]
and the
median survival rate after diagnosis of &I'( in resource.limited settings
here treatment is not available ranges beteen 0 and 16 months! depending
on the study.
[1#1]
In areas here it is idely available! the development of
H&&>T as effective therapy for HIV infection and &I'( reduced the death
rate from this disease by 7*K! and raised the life e%pectancy for a nely.
diagnosed HIV.infected person to about #* years.
[1##]
&s ne treatments continue to be developed and because HIV continues to
evolve resistance to treatments! estimates of survival time are li"ely to
continue to change. Bithout antiretroviral therapy! death normally occurs
ithin a year.
[$1]
1ost patients die from opportunistic infections or
malignancies associated ith the progressive failure of the immune system.
[1#$]
The rate of clinical disease progression varies idely beteen
individuals and has been shon to be affected by many factors such as host
susceptibility and immune function
[$#][$$][$0]
health care and co.infections!
[$1]
[1#$]
as ell as hich particular strain of the virus is involved.
[$7][1#)][1#,]
AIDS denialism
& small group of activists! including several scientists ho do not study
HIVF&I'(! /uestion the connection beteen HIV and &I'(!
[1),]
the
e%istence of HIV itself!
[1)0]
or the validity of current testing and treatment
methods. Though these claims have been e%amined and thoroughly reLected
by the scientific community!
[1)+]
they continue to be promulgated through the
Internet
[1)7]
and have had a significant political impact! particularly in (outh
&frica! here 5resident Thabo 1be"iAs embrace of &I'( denialism has
been blamed for an ineffective response to that countryAs &I'( epidemic.
[1)6]
[1,*][1,1]