
Human Immunodeficiency Virus
The human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS), principally attacks CD4 T-cells, a vital part of the human immune system. As a result, the body’s ability to resist opportunistic viral, bacterial, fungal, protozoal, and other infection is greatly weakened. Pneumocystis carinii pneumonia is the leading cause of death among people with HIV infection, but the incidence of certain types of cancers such as B-cell lymphomas and Kaposi’s sarcoma is also increased. Neurological complications and dramatic weight loss, or “wasting,” are characteristic of endstage HIV disease (AIDS). HIV can be transmitted sexually; through contact with contaminated blood, tissue, or needles; and from mother to child during birth or breastfeeding. Full-blown symptoms of AIDS may not develop for more than 10 years after infection.
Acquired Immunodeficiency Syndrome (AIDS), human viral disease that ravages the immune system, undermining the body’s ability to defend itself from infection and disease. Caused by the human immunodeficiency virus (HIV), AIDS leaves an infected person vulnerable to opportunistic infections—infection by microbes that take advantage of a weakened immune system. Such infections are usually harmless in healthy people but can prove life-threatening to people with AIDS. Although there is no cure for AIDS, new drugs are available that can prolong the life spans and improve the quality of life of infected people.
Transmission of HIV—the AIDS-causing virus—occurs most commonly as a result of sexual intercourse. HIV also can be transmitted through transfusions of HIV-contaminated blood or by using a contaminated needle or syringe to inject drugs into the bloodstream. Infection with HIV does not necessarily mean that a person has AIDS. Some people who have HIV infection may not develop any of the clinical illnesses that define the full-blown disease of AIDS for ten years or more. Physicians prefer to use the term AIDS for cases where a person has reached the final, life-threatening stage of HIV infection.
AIDS is one of the deadliest epidemics in human history. It was first identified in 1981 among homosexual men and intravenous drug users in New York and California. Shortly after its detection in the United States, evidence of AIDS epidemics grew among heterosexual men, women, and children in sub-Saharan Africa. AIDS quickly developed into a worldwide epidemic, affecting virtually every nation. The United Nations Program on HIV/AIDS (UNAIDS) estimates that the worldwide number of new cases of HIV infection peaked in the late 1990s with more than 3 million people newly infected each year. However, some regions of the world, especially Vietnam, Indonesia, and other countries in southeast Asia, continued to see an increase in the early 2000s. In addition, the number of people living with HIV or AIDS has continued to rise as the result of new drug treatments that lengthen life.

A Global Epidemic
More than 42 million people around the world are currently infected with human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS). New HIV infections have leveled off or even declined in most developed countries, but the virus is spreading rapidly through much of the developing world. In some areas of sub-Saharan Africa, one in four adults is carrying the virus.
While cases of AIDS have been reported in every nation of the world, the disease affects some countries more than others. About 90 percent of all HIV-infected people live in the developing world. AIDS has struck sub-Saharan Africa particularly hard. Two-thirds of all people living with HIV infection reside in African countries south of the Sahara, where AIDS is the leading cause of death.
In countries hardest hit, AIDS has sapped the population of young men and women who form the foundation of the labor force. Most die while in the peak of their reproductive years. Moreover, the epidemic has overwhelmed health-care systems, increased the number of orphans, and caused life expectancy rates to plummet. These problems have reached crisis proportions in parts of the world already burdened by war, political upheaval, or unrelenting poverty.
AIDS is the final stage of a chronic infection with the human immunodeficiency virus. There are two types of this virus: HIV-1, which is the primary cause of AIDS worldwide, and HIV-2, found mostly in West Africa. Inside the body HIV enters cells of the immune system, especially white blood cells known as T cells. These cells orchestrate a wide variety of disease-fighting mechanisms. Particularly vulnerable to HIV attack are specialized “helper” T cells known as CD4 cells. When HIV infects a CD4 cell, it commandeers the genetic tools within the cell to manufacture new HIV virus. The newly formed HIV virus then leaves the cell, destroying the CD4 cell in the process. No existing medical treatment can completely eradicate HIV from the body once it has infected human cells.
The loss of CD4 cells endangers health because these cells help other types of immune cells respond to invading organisms. The average healthy person has over 1,000 CD4 cells per microliter of blood. In a person infected with HIV, the virus steadily destroys CD4 cells over a period of years, diminishing the cells’ protective ability and weakening the immune system. When the density of CD4 cells drops to 200 cells per microliter of blood, the infected person becomes vulnerable to AIDS-related opportunistic infections and rare cancers, which take advantage of the weakened immune defenses to cause disease.
Scientists have identified three ways that HIV infections spread: sexual intercourse with an infected person, contact with contaminated blood, and transmission from an infected mother to her child before or during birth or through breast-feeding.
HIV transmission occurs most commonly during intimate sexual contact with an infected person, including genital, anal, and oral sex. The virus is present in the infected person’s semen or vaginal fluids. During sexual intercourse, the virus gains access to the bloodstream of the uninfected person by passing through openings in the mucous membrane—the protective tissue layer that lines the mouth, vagina, and rectum—and through breaks in the skin of the penis. In the United States and Canada, HIV is most commonly transmitted during sex between men, but the incidence of HIV transmission between men and women has rapidly increased. In most other parts of the world, HIV is most commonly transmitted through heterosexual sex.
Direct contact with HIV-infected blood occurs when people who use heroin or other injected drugs share hypodermic needles or syringes contaminated with infected blood. Sharing of contaminated needles among intravenous drug users has been a primary cause of HIV infection in parts of eastern Europe and central Asia.
Less frequently, HIV infection results when health professionals accidentally stick themselves with needles containing HIV-infected blood or expose an open cut to contaminated blood. Some cases of HIV transmission from transfusions of infected blood, blood components, and organ donations were reported in the 1980s. Since 1985 government regulations in the United States and Canada have required that all donated blood and body tissues be screened for the presence of HIV before being used in medical procedures. As a result of these regulations, HIV transmission caused by contaminated blood transfusion or organ donations is rare in North America. However, the problem continues to concern health officials in sub-Saharan Africa.
HIV can be transmitted from an infected mother to her baby while the baby is still in the woman’s uterus or, more commonly, during childbirth. The virus can also be transmitted through the mother’s breast milk during breast-feeding. Mother-to-child transmission accounts for 90 percent of all cases of AIDS in children. Mother-to-child transmission is particularly prevalent in Africa.
The routes of HIV transmission are well documented by scientists, but health officials continually grapple with people’s unfounded fears concerning the potential for HIV transmission by other means. HIV differs from other infectious viruses in that it dies quickly if exposed to the environment. No evidence has linked HIV transmission to casual contact with an infected person, such as a handshake, hugging, or kissing, or even sharing dishes or bathroom facilities. Studies have been unable to identify HIV transmission from modes common to other infectious diseases, such as an insect bite or inhaling virus-infected droplets from an infected person’s sneeze or cough.
Without medical intervention, AIDS progresses along a typical course. Within one to three weeks after infection with HIV, most people experience flu-like symptoms, such as fever, sore throat, headache, skin rash, tender lymph nodes, and a vague feeling of discomfort. These symptoms last one to four weeks. During this phase, known as acute retroviral syndrome, HIV reproduces rapidly in the blood. The virus circulates in the blood throughout the body, particularly concentrating in organs of the lymphatic system.
The normal immune defenses against viral infections eventually activate to battle HIV in the body, reducing but not eliminating HIV in the blood. Infected individuals typically enter a prolonged asymptomatic phase, a symptom-free period that can last ten years or more. While persons who have HIV may remain in good health during this period, HIV continues to replicate, progressively destroying the immune system. Often an infected person remains unaware that he or she carries HIV and unknowingly transmits the virus to others during this phase of the infection.
When HIV infection reduces the number of CD4 cells from around 500 to 200 per microliter of blood, the infected individual enters an early symptomatic phase that may last a few months to several years. HIV-infected persons in this stage may experience a variety of symptoms that are not life-threatening but may be debilitating. These symptoms include extensive weight loss and fatigue (wasting syndrome), periodic fever, recurring diarrhea, and thrush, a fungal mouth infection. An early symptom of HIV infection in women is a recurring vaginal yeast infection. Unlike earlier stages of the disease, in this early symptomatic phase the symptoms that develop are severe enough to cause people to seek medical treatment. Many may first learn of their infection in this phase.
If CD4 cell levels drop below 200 cells per microliter of blood, the late symptomatic phase develops. This phase is characterized by the appearance of any of the opportunistic infections and rare cancers known as AIDS-defining conditions. The onset of these illnesses is a sign that an HIV-infected person has developed full-blown AIDS. Without medical treatment, this stage may last from several months to years. The cumulative effects of these illnesses usually cause death.
Often the first opportunistic infection to develop is pneumocystis pneumonia, a lung infection caused by the fungus Pneumocystis carinii. This fungus infects most people in childhood, settling harmlessly in the lungs where it is prevented from causing disease by the immune system. But once the immune system becomes weakened, the fungus can block the lungs from delivering sufficient oxygen to the blood. The lack of oxygen leads to severe shortness of breath accompanied by fever and a dry cough.
In addition to pneumocystis pneumonia, people with AIDS often develop other fungal infections. Up to 23 percent of people with AIDS become infected with fungi from the genus Cryptococcus, which cause meningitis, inflammation of the membranes that surround the brain. Infection by the fungus Histoplasma capsulatum affects up to 10 percent of people with AIDS, causing general weight loss, fever, and respiratory complications.
Tuberculosis, a severe lung infection caused by the bacterium Mycobacterium tuberculosis, typically becomes more severe in AIDS patients than in those with a healthy immune system. Between the 1950s and the late 1980s, tuberculosis was practically eradicated in North America. In the early 1990s, doctors became alarmed when incidence of the disease dramatically escalated. This resurgence was attributed to the increased susceptibility to tuberculosis of people infected with HIV. Infection by the bacterium Mycobacterium avium can cause fever, anemia, and diarrhea. Bacterial infections of the gastrointestinal tract contribute to wasting syndrome.
Opportunistic infections caused by viruses, especially members of the herpesvirus family, are common in people with AIDS. One of the herpesviruses, cytomegalovirus (CMV), infects the retina of the eye and can result in blindness. Another herpesvirus, Epstein-Barr virus (EBV), may cause certain types of blood cancers. Infections with herpes simplex virus (HSV) types 1 or 2 may result in sores around the mouth, genital area, or anus.
Many people with AIDS develop cancers. The destruction of CD4 cells impairs the immune functions that halt the development of cancer. Kaposi’s sarcoma is a cancer of blood vessels caused by a herpesvirus. This cancer produces purple lesions on the skin, which can spread to internal organs and cause death. B cell lymphoma affects certain cells of the lymphatic system that fight infection and perform other vital functions. Cervical cancer is more common in HIV-infected women than in women free from infection.
A variety of neurological disorders are common in the later stage of AIDS. Collectively called HIV-associated dementia, they develop when HIV or another microbial organism infects the brain. The infection produces degeneration of intellectual processes such as memory and, sometimes, problems with movement and coordination.
HIV infection in children progresses more rapidly than in adults, most likely because a child’s immune system has not yet built up immunity to many infectious agents. The disease is particularly aggressive in infants—more than half of infants born with an HIV infection die before age two. Once a child is infected, the child’s undeveloped immune system cannot prevent the virus from multiplying quickly in the blood, and the disease progresses rapidly. In contrast, when an adult becomes infected with HIV, the adult’s immune system generally fights the infection. Therefore, HIV levels in adults remain lower for an extended period, delaying the progression of the disease.
Children develop many of the opportunistic infections that befall adults but also exhibit symptoms not observed in older patients. Among infants and children, HIV infection produces wasting syndrome and slows growth (generally referred to as failure to thrive). HIV typically infects a child’s brain early in the course of the disease, impairing intellectual development and coordination skills. While HIV can infect the brains of adults, it usually does so toward the later stages of the disease and produces different symptoms.
Children show a susceptibility to more bacterial and viral infections than adults. More than 20 percent of HIV-infected children develop serious, recurring bacterial infections, including meningitis and pneumonia. Some HIV-infected children suffer from repeated bouts of viral infections, such as chicken pox. Healthy children generally develop immunity to these viral illnesses after an initial infection.
Since HIV was first identified as the cause of AIDS in 1983, a variety of tests have been developed that help diagnose HIV infection as well as determine how far the infection has progressed. Other tests can be used to screen donated blood, blood products, and body organs for the presence of HIV.
Doctors determine if HIV is present in the body by identifying HIV antibodies, specialized proteins created by the immune system to destroy HIV. The presence of these antibodies indicates HIV infection because they form in the body only when HIV is present. HIV antibodies form anywhere from five weeks to three months after HIV infection occurs, depending upon the individual’s immune system. The antibodies are produced continually throughout the course of the infection.
The standard test to detect HIV antibodies in the blood is the enzyme-linked immunosorbent assay (ELISA). In this test, a blood sample is mixed with proteins from HIV. If the blood contains HIV antibodies, they attach to the HIV proteins, producing a telltale color change in the mixture. This test is highly reliable when performed two to three months after infection with HIV. The test is less reliable when used in the very early stage of HIV infection, before detectable levels of antibodies have had a chance to form. Doctors routinely confirm a positive result from an ELISA test by using the Western Blot test, which can detect lower levels of HIV antibodies. In this test a blood sample is applied to a paper strip containing HIV proteins. If HIV antibodies are present in the blood, they bind to the HIV proteins, producing a color change on the paper. The combination of the ELISA and the Western Blot test is more than 99.9 percent accurate in detecting HIV infection within 12 weeks following exposure.
Once tests confirm an HIV infection, doctors monitor the health of the infected person’s immune system by periodically measuring CD4 cell counts in the blood. The progressive loss of CD4 cells corresponds to a worsening of the disease as the immune system becomes increasingly impaired. Doctors also measure the viral load—the amount of the virus in the blood—using polymerase chain reaction (PCR) technology. PCR tests measure the level of viral ribonucleic acid (RNA), or HIV particles, in an infected person’s blood to determine how actively the virus is replicating and how fast the disease is progressing. Knowing the viral load helps doctors make decisions about the treatment and its effectiveness.
A modified ELISA test that detects p24 antigen, a protein produced by HIV, can determine if specific drug treatments are having a positive effect on a patient. Blood banks, plasma centers, clinical laboratories, private clinics, and public health departments also use this p24 antigen test to screen for the presence of HIV in blood, blood components, and organs before they are used in medical procedures.
Physicians prefer to differentiate between people who have HIV infection and those who have AIDS. The Centers for Disease Control and Prevention (CDC), based in Atlanta, Georgia, recommends that physicians reserve the diagnosis of AIDS for HIV-infected individuals whose CD4 count falls below 200 cells per microliter of blood. A diagnosis of AIDS can also be made without confirmation of CD4 levels if someone who has no other reason for immune system damage develops an opportunistic disease.
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