HIV and AIDS

Introduction

Barely 25 years ago few people knew what the words AIDS and HIV meant. Now not only are red ribbons the standard attire on guests at television awards shows, but there are specific lines of clothing and cell phones dedicated to raise money and awareness of this deadly virus.

What is it?

AIDS stands for Acquired Immune Deficiency Syndrome. People with AIDS are infected with the human immunodeficiency virus (HIV), a virus that damages the immune system. Since the immune system protects the body from illness, people with AIDS are more susceptible to all sorts of other health problems. Currently, AIDS cannot be cured. However, AIDS has evolved from a relatively untreatable, almost always fatal disease into a complex, long-term illness for which patients and their caregivers have numerous treatment options. Therapies have been developed to treat both the virus itself and its associated complications.

What causes it?

Acquired Immune Deficiency Syndrome, or AIDS, is caused by an infection with a specific virus - human immunodeficiency virus (HIV). AIDS is the last stage of the HIV infection. When HIV enters the body, it attacks special white blood cells that are part of your body's immune system. These cells, called CD4 cells or T cells, play an important role in fighting infections as well as in directing other cells to find and destroy disease-causing organisms. After invading a cell, HIV releases an enzyme called reverse transcriptase that helps it grow and multiply inside the CD4 cell. HIV then uses another enzyme, protease, to make pieces of virus to spread throughout the body. As HIV disables and kills more and more CD4 cells, the body's ability to fight infection weakens.

AIDS is diagnosed when CD4 cell count drops below 200 cells per cubic millimeter of blood. (Healthy adults usually have CD4 counts of 1000 or more). A diagnosis of AIDS is also given when one or more of the 26 clinical conditions that often affect people with advanced HIV disease are present. Most of these conditions are infections that generally do not affect healthy people. In individuals with AIDS, these infections are often severe and sometimes fatal because the immune system is so weakened by HIV that the body cannot fight off certain bacteria, viruses, fungi, other microbes,and even certain cancers.

Who has it?

AIDS can strike individuals in all ethnic groups, ages, sexes, and sexual orientations. According to the World Health Organization (WHO), as of November, 2007, 33.2 million people worldwide were living with HIV/AIDS, with approximately 68% (22.5 million) of these people live in Sub-Saharan Africa and 50% being of the male gender. In the year 2006, 4.3 million individuals were diagnosed with HIV, which means that roughly 14,000 individuals were diagnosed each day. Approximately 95% of those new infections are occurring in developing countries such as: Bangladesh, Pakistan, Indonesia, Papua New Guinea, and Vietnam. Also, in the year 2006, there was an estimated 2.9 million deaths associated with HIV/AIDS.HIV continues to be one of the major causes of death globally, and it is the number one cause of death in sub-Sahara Africa.

As of March 2008, in the United States, it is estimated that 1.2 million residents are living with HIV/AIDS, 25% of whom are unaware that they are infected. Approximately 40,000 new cases are diagnosed each year, with 70% being males and 50% being individuals under the age of 25.

What are the risk factors?

HIV infection is spread by the transmission of body fluids from a person who is infected with HIV. Anybody, regardless of age, geographic location, gender, or sexual preference is at risk for HIV. For example, any of the following are ways of contracting HIV:

  • Having unprotected sex, including vaginal, oral, and anal (without a latex condom) with a person who is infected with HIV whether they are heterosexual, homosexual, or bisexual.
  • Having STI?s (sexually transmitted infections) such as syphilis, herpes, chlamydia, or gonorrhea.
  • Sharing a needle or syringe with an HIV-positive individual.
  • Receiving an HIV-contaminated blood transfusion or any blood product prior to 1985.
  • Being born to or breastfeeding from an un-medicated HIV-positive woman.
  • Breaking the skin with an injury from medical equipment that has been in contact with HIV-infected fluids. (eg. accidentally pricking the finger with a needle that was used in an HIV-positive patient)
  • Receiving an HIV-contaminated organ transplant (very rare).
  • Undergoing dental procedures done with improper sanitation of dental equipment that has been in contact with HIV (very rare).
  • Getting a tattoo or body piercing with equipment that was not sanitized properly, or with needles that have been reused.

Within the past 15 years, many efforts have been made to reduce the risk of being infected with HIV. For instance, since 1985 the American blood supply has been tested for HIV, making infections through blood transfusions very rare. HIV infection is NOT spread by:

  • Air
  • Food
  • Water
  • Insects (including mosquitoes and bedbugs)
  • Animals
  • Non-infected people wanting to donate blood
  • Everyday, casual contact with people who are HIV-positive (eg. sharing food, utensils, towels, bedding, telephones, toilet seats, swimming pools, and hand shaking)
  • Saliva from kissing, sweat, tears, urine, feces

What are the symptoms?

A person who has been infected with HIV is usually referred to as being "HIV-positive". The time between a diagnosis of HIV and the onset of AIDS can vary greatly. Whereas many HIV-positive individuals remain symptom-free for several years, most will develop at least some AIDS-related condition within 10 years.

Many people do not develop any symptoms when they first become infected with HIV. Others may suffer a brief flu-like illness, with symptoms that may include the following:

  • Fever
  • Headaches
  • Tiredness
  • Sore throat
  • Swollen glands
  • Muscle and joint pain

As the immune system loses its ability to fight infection, serious illnesses, called opportunistic infections, may appear. Opportunistic infections result when microorganisms that do not ordinarily cause problems in healthy people take advantage of a weakened immune system and attack the body. Common sites for some of these infections are the following:

  • Esophagus
  • Lungs
  • Brain or spinal cord
  • Retina (an organ located behind the eye that is ultimately responsible for vision)

Symptoms of opportunistic infections can include the following:

  • Upset stomach
  • Vomiting
  • Diarrhea
  • Stomach cramps
  • Coughing
  • Fever
  • Headaches
  • Vision loss
  • Weight loss
  • Tiredness, lack of energy
  • Painful swallowing
  • Mental symptoms including confusion and forgetfulness
  • Seizures, lack of coordination

How is it treated?

AIDS has no cure and there are currently no FDA-approved vaccines to protect against HIV, but there are vaccines that are currently being studied. However, medications can slow the progress of the disease, which allows patients to stay healthier and live longer. The drugs used to treat HIV infection are called antiretrovirals, because they fight HIV, which is a type of "retrovirus."

The goals of therapy are to:

  • Suppress viral load (or the amount of HIV in a sample of blood)
  • Restore or preserve immune function
  • Improve quality of life
  • Reduce morbidity (the occurrence of opportunistic infections or number of hospitalizations) and mortality (death)
  • Reduce the transmission of HIV/AIDS

The six types of currently FDA-approved antiretroviral medications used to treat HIV and AIDS are:

  1. Nucleoside Reverse Transcriptase Inhibitors (NRTIs), which includes Nucleotide Analogs
  2. Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
  3. Protease Inhibitors
  4. Fusion Inhibitors, sometimes also referred to as Entry Inhibitors
  5. CCR5 Entry Inhibitors, sometimes also referred to as CCR5 Co-receptor Antagonist
  6. Integrase Inhibitors

How These Drugs Work:

Antiretroviral drugs inhibit the growth and replication of HIV at various stages of its life cycle. NRTIs interrupt an early stage of the virus replication process (or interrupt the virus from making copies of itself). NRTIs help to slow the spread of HIV in the body and delay the start of other opportunistic infections. NNRTIs keep the enzyme called "reverse transcriptase" from working so viral cells cannot reproduce. Protease Inhibitors interrupt virus replication at a later step in the HIV life cycle. Nucleotide Analogs prevent the HIV cells from producing new virus and decrease the amount of HIV in the body. Fusion Inhibitors bind to HIV and prevent the virus from infecting healthy cells in the body. CCR5 Entry Inhibitors work by binding to CD4 cells and prevent the HIV virus from entering CD4 cells. Integrase Inhibitors work by stopping viral genetic material from being integrated into healthy host cell genetic material.

Recommended Treatment Options:

According to the guidelines for the use of antiretroviral agents,

  • treatment is typically not started in individuals who have a CD4+ T cell count of greater than 350 cells/mm3 and plasma HIV RNA levels of less than 100,000 copies/mL.
  • clinicians may consider starting therapy for individuals who have a CD4+ count of more than 350 cells/mm3 and a plasma HIV RNA level of more than 100,000 copies/mL and are not showing signs or symptoms of HIV, whereas some clinicians may choose to delay starting therapy.
  • individuals who have a CD4+ count of 201to 350 cells/mm3 and any level of plasma HIV RNA are offered the option to start treatment, but it is up to the individual.
  • treatment is recommended in those individuals who have a CD4+ count of less than 200 cells/mm3 even if they are not showing signs or symptoms of HIV/AIDS.
  • treatment is recommended in those individuals who have severe symptoms of HIV infection or who have a history of AIDS-defining illnesses (such as multiple/recurrent bacterial infections, recent pneumonia, fungal infection in the esophagus, herpes simplex virus, kaposi's sarcoma-a type of skin cancer, burkitt's lymphoma-a type of cancer, invasive cervical cancer, as well as any other opportunistic infections just to name a few) no matter what their CD4+ count is.

Highly Active Anti-Retroviral Therapy (HAART) is a combination of different classes of drugs that are used to treat HIV/AIDS. This therapy focuses on maximizing suppression of the individual's symptoms of HIV and prolonging the development of opportunistic infections. The treatment guidelines recommend two different types of regimens for those individuals who have not been placed on HAART before. Both regimens include the use of 2 NRTIs as the basis of therapy. One of the regimens recommends the additional use of 1 NNRTI agent (so, 2 NRTIs plus 1 NNRTI) while the other recommends the additional use of 1 to 2 PIs (so, 2 NNRTIs plus 1 to 2 PIs). Studies have shown that the combination of zidovudine, lamivudine (both are NRTIs ), and efavirenz (an NNRTI) is a regimen that is superior over other regimens for initial therapy.Fusion inhibitors, CCR5 Co-Receptor Antagonists, and Integrase Inhibitors are typically used in place of protease inhibitors, NRTIs, or NNRTI in cases of resistant HIV.

Unfortunately, the HIV/AIDS virus typically becomes resistant to medications due to viral mutations or changes. Also, over time, individuals may become intolerant to the medication or the medication?s side effects which can be very unpleasant. With resistance developing or if medication intolerance occurs, 1 to 2 medications might have to changed at some point during therapy.

Combination Medications:

Due to the need of a large number of medications used to treat HIV, drug companies have started to create combination medications. Some of these combination medications contain up to three different HIV medication ingredients to help reduce the number of pills taken per day and to help individuals remember to take all medications. Here is a list of all currently available combination medications: Trizivir, Epzicom, Truvada, Combivir, and Atripla. Some of the combination medications contain drugs from the same class, but not all of them.

Resistance Testing:

When individuals who are infected with HIV become resistant to a particular treatment regimen, a new regimen should be tried. But how do doctors know if the new treatment will work? Persons who fail a certain combination of antiretroviral drugs can undergo resistance testing (sometimes called genotype testing) before starting a new treatment regimen. This type of testing may help health care providers find the most effective treatment regimen for the resistant infection. Also, since resistant HIV can be transmitted to others, some newly diagnosed patients who have not been on antiretroviral drugs previously may also undergo resistance testing to find the most appropriate drugs even before beginning treatment.

The treatment guidelines provide recommendations on when an individual should have resistance testing done. Resistance testing should be performed in those individuals who:

  • have an acute HIV infection and therapy is going to be started (often times an acute infection goes unrecognized as it presents with similar symptoms to the flu and other illnesses, symptoms include: fever, rash, headache, nausea/vomiting, weight loss. HIV RNA tests are done to then confirm diagnosis.)
  • have a chronic HIV infection and therapy is going to be started
  • have suboptimal viral load reduction

Resistance testing should be considered in those individuals who have an acute HIV infection, but therapy is going to be started at a later time. However, resistance testing may not be beneficial for all patients with HIV/AIDS. Your doctor can decide if resistance testing is right for you.

Finally, it is important to note that individuals who are infected with HIV should seek medical care from doctors who are specially trained and have expertise in treating HIV/AIDS. We are learning more and more about HIV/AIDS on a daily basis. Research into new drug therapies and treatments is ongoing. Seeking medical care from an HIV/AIDS specialist will help you ensure that you are receiving the most cutting-edge therapy and care. An HIV/AIDS specialist will best be able to determine when to start HIV treatment and what HAART regimen is best.

To learn more about the different drug classes used to treat HIV/AIDS, click on the links below.

Helping Yourself

The ability to comply with recommended medications and lifestyle changes is critical for successful treatment of HIV and AIDS. Drug therapy for HIV usually requires that several different medications be taken exactly as prescribed, often several times a day and sometimes with food. Not following instructions may allow HIV to become resistant to the drugs, making the medications ineffective. Treatment of HIV infection and AIDS involves:

  • Frequent monitoring, often with blood testing
    • Viral Load Test - measures the amount of HIV in a sample of blood
      • Shows how well your body's immune system and medications are controlling the virus
      • Provides a measurement at the time of diagnosis and is also used later on to help determine whether your disease has progressed
    • CD4+ T Cell Count - number of CD4+ T Cells in a sample of blood
      • Shows how well your body's immune system and medications are working
      • Provides a measurement at the time of diagnosis and is also used later on to help determine whether your disease has progressed
  • Vaccinations for preventable infections such as pneumonia, influenza, and hepatitis
  • Medications to slow or halt the spread of the HIV virus
  • Drugs to prevent or treat opportunistic infections

Other Tips:

  • Follow your doctor's instructions. Keep all of your appointments, and take your medications exactly as directed. This is often challenging because you may have to take a number of medications at specific times throughout the day. But it is essential to follow your schedule as closely as possible. If you get sick from your medication, call your doctor. Don't stop taking your medication or change the dosage on your own.

  • Don't smoke or use illegal drugs. These weaken your body even more.

  • Eat the healthiest diet you can. Emphasize fresh fruits and vegetables, whole grains and lean protein. Healthy foods help keep you strong, give you more energy and support your immune system. Unfortunately, you may not always feel like eating when you have HIV. But good nutrition is tremendously important. A registered dietitian can be especially helpful if you have diarrhea, weight loss or trouble eating. Also, because your nutritional needs are extremely high and you may not digest food well, talk to your doctor about vitamin and mineral supplements.

  • Avoid foods that may put you at risk of infection. These include non-pasteurized dairy products, raw eggs and raw seafood such as oysters, sushi or sashimi. Cook meat until it's well-done or until there's no trace of pink color.

  • Drink pure water. The Department of Health and Human Services recommends that you boil tap water or use bottled or filtered water for drinking. If you buy a water filter, look for one that uses reverse osmosis as part of the purification process.

  • Get regular exercise. Exercise helps increase your strength and energy levels and can help battle the depression that's often a part of dealing with HIV/AIDS. Talk to your doctor about what kind of exercise is right for you.

  • Get enough sleep. Rest when you need to.

  • Take care with companion animals. Some animals may carry parasites that can cause infections in people who are HIV-positive. But that doesn't mean you should give up your companion animal. Animals are a great source of comfort. You can protect yourself by having someone else clean your cat's litter box or pick up after your dog. If you must do these chores yourself, wear latex gloves and wash your hands immediately afterward. Don't feed your pets raw meat, and make sure they have all of their shots. Always wash your hands thoroughly with soap and water after petting or playing with your animals.

  • Find ways to relax. This might mean anything from yoga or meditation to walking, reading, playing chess or computer games, or listening to music.

  • Keep your hands clean. Wash your hands thoroughly with soap and water after using the restroom, before eating or preparing food and after spending time in public places. You might find it helpful to carry a waterless alcohol gel with you for times when it's not convenient to use soap and water.

It is very important to see your doctor regularly. You are encouraged to be an active member of your health care team and to continuously educate yourself about this disease.

Safe Sex:

The only way to prevent spreading HIV or becoming infected with the HIV virus is to avoid behaviors that put a person at risk of infection, such as sharing needles or having unprotected sex. There is no way to know for certain that a sexual partner does not have the virus unless an HIV test yields a negative result and he or she has not engaged in any risky behaviors. The best way to obtain protection from getting infected with the virus is to either abstain from having sex or use a male latex condom or a female polyurethane condom during oral, anal, or vaginal sex.

What is on the horizon?

Different combinations of new and existing drugs are being studied to find the best possible treatments for HIV. Also, the time it takes to discover, develop, and make new drugs available to patients with HIV/AIDS has been shortened considerably over the last 10 years. AIDS patients now have access to the latest breakthroughs more quickly than ever before.

The Pharmaceutical Research and Manufacturers Association lists nearly two dozen new anti-HIV drugs now in development. They include new, more potent, less toxic reverse transcriptase inhibitors. There are currently two new Integrase Inhibitors being studied under the code names: JTK-303 and GSK364735. A key element of JTK-303 is unlike many other anti-retrovirals it is eliminated almost entirely in feces, instead of by the kidneys, which would then not need dosage adjustments in those with kidney problems. A new class of drugs is also being developed and studied--a class called Maturation Inhibitors. The code name for the first drug in this class is PA457. It is already in clinical trials and is showing strong anti-retroviral activity with minimal side effects. Research is currently being conducted on a new integrase inhibitor called Raltegravir in combination with 2 NRTIs. It is now undergoing phase III trials with much promise. There is also a new CCR5 co-receptor antagonist being studied called Maraviroc. The MERIT trial is currently comparing it to efavirenz for safety and efficacy (both treatments are in combination with zidovudine and lamivudine).

Although there is a rise in the number of HIV/AIDS individuals who either have a resistant strain of the virus or who have developed resistance to one or more antiretroviral drugs, research for new drugs is always ongoing and promising.

Other new therapies are targeted at inhibiting HIV in different stages of its life cycle. DNA profiling is being used to manufacture drugs aimed at interfering with any of HIV's nine known genes. Experts caution it is extremely unlikely that any one of these new drugs could be used solely in the treatment of AIDS. However, if these agents have improved safety or efficacy profiles, treatment regimens may be simplified and more tolerable.

A new prevention therapy is also being developed. Microbicides are currently being studied for the prevention of HIV in females. This new therapy is inserted before sexual intercourse, but it does not appear to be as effective as latex condoms for HIV prevention.

In addition, research continues to focus on developing and testing potential HIV vaccines and searching for a cure. The goal is to develop a vaccine that can protect people from HIV, or at least decrease the risk of getting HIV or AIDS if people are exposed to the virus. This type of vaccine is called a preventive vaccine. Another type of vaccine, referred to as a therapeutic vaccine, is being designed to help boost the immune system of people who already have HIV/AIDS so that they may better fight the infection. Several vaccines are currently being tested in clinical trials; however, these studies are in the very early stages and it will take many years to determine whether the vaccines are safe and effective. According to the timeline provided by the HIV Vaccine Trials network, large scale trials will be conducted during 2010 and 2011 to test the preventative vaccines.

References

Center for Disease Control and Prevention: National AIDS Hotline. [resource World Wide Web] Available at: http://www.ashastd.org/nah/. Accessed September 21, 2006.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. Updated October 2006. [resource World Wide Web] Available at: http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed September 21, 2006, June 19, 2007, and May 22, 2008.

HIV/AIDS Treatment Information Service Home Page [resource World Wide Web]. Available at: http://hivatis.org. Accessed September 21, 2006, and May 22, 2008.

HIV Infection and AIDS: An Overiew. [resource World Wide Web]. Available at: http://www.niaid.nih.gov/factsheets/hivinf.htm. Accessed September 21, 2006, June 19, 2007, and May 22, 2008.

Mayo Clinic. Diseases and Conditions. Available at URL: http://www.mayoclinic.com/health/hiv-aids/DS00005 Accessed May 22, 2008.

Carpenter CCJ, Fischl MA, Hammer SM, and others. Antiretroviral therapy for HIV infection in 1997. Updated recommendations of the International AIDS Society-USA Panel. Journal of the American Medical Association. 1997;277:1962-1969.

Center for Disease Control and Prevention Home Page [resource World Wide Web]. Available at: http://www.cdc.gov. Accessed September 21, 2006, and May 22, 2008.

Center for Disease Control and Prevention Home Page. Available at: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/pdf/2005SurveillanceReport.pdf. Accessed June 19, 2007

Fletcher CV and Kakuda TN. Himan Immunodeficiency Virus Infection. In: Dipiro JT, Talbert, RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York: McGraw-Hill; 2005.

HIV Insite Home Page [resource World Wide Web]. Available at: http://hivinsite.ucsf.edu. Accessed July, 13 2005.

Merigan TC, Bartlett JG, and Bolognesi D, eds. Textbook of AIDS Medicine. 2nd ed. Baltimore: Williams & Wilkins; 1999.

FDA website http://www.fda.gov/oashi/aids/news.html Accessed: July 12, 2005

FDA website http://www.fda.gov/oashi/aids/viralsgeneric.html Accessed: June 19, 2007

Federal HIV/AIDS Information. Available at: http://aids.gov/basic/index.html. Accessed June 19, 2007

St. Luke's Cataract and Laser Institute. Available at: http://www.stlukeseye.com/anatomy/Retina.asp . Accessed June 20, 2007

HIV Vaccine and Trials Network. Available at: http://avac.org/timeline-website/index.htm. Accessed June 25, 2007, and My 22, 2008.

New Mexico AIDS Education and Training Center a Division of the University of New Mexico School of Medicine. Available at: http://www.aidsinfonet.org/factsheet_detail.php?fsnumber=470&newLang=en. Accessed May 22,2008.

HIV/AIDS Treatment Formulations. Available at: http://aidsinfo.nih.gov/ContentFiles/AntiretroviralFormulations_FS_en.pdf. Accessed on May 22, 2008

Henry J Kaiser Family Foundation. Available at: http://www.kff.org/hivaids/upload/3029-08.pdf, and http://www.kff.org/hivaids/upload/3030-103.pdf. Accessed on May 28, 2008.

HIV and AIDS Health Condition Last Updated: June 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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