Acquired immune deficiency syndrome (AIDS) is an infectious disease caused by the human immunodeficiency virus (HIV). It was first recognized in the United States in 1981. AIDS is the advanced form of infection with the HIV virus, which may not cause disease for a long period after the initial exposure (latency). Infection with HIV weakens the immune system which makes infected people susceptible to infection and cancer.
AIDS is considered one of the most devastating public health problems in recent history. In 1996, the Centers for Disease Control and Prevention (CDC) estimated that one million persons in the United States were HIV-positive, and 223,000 are living with AIDS. Of these patients, 44% were gay or bisexual men, 26% are heterosexual intravenous drug users, and 18% were women. In addition, approximately 1,000-2,000 children are born each year with HIV infection. In 2002, the CDC reported 42,136 new AIDS diagnoses in the United States, a 2.2% increase from the previous year. AIDS cases rose among gay and bisexual men (7.1% in 25 states that report regularly). The disease also seems to be rising among older Americans. From 1990 to 2001, the number of cases in Americans age 50 years or older rose from 16,288 to 90,153.
The World Health Organization (WHO) estimates that 40 million people worldwide were infected with AIDS/HIV as of 2001. Most of these cases are in the developing countries of Asia and Africa. In 2003, WHO cautioned that if treatment were not delivered soon to nearly 6 million people with AIDS in developing countries, there could be 45 million cases by 2010.
AIDS can be transmitted in several ways. The risk factors for HIV transmission vary according to category:
- Sexual contact. Persons at greatest risk are those who do not practice safe sex, are not monogamous, participate in anal intercourse, and have sex with a partner with symptoms of advanced HIV infection and/or other sexually transmitted diseases (STDs). In the United States and Europe, most cases of sexually transmitted HIV infection have resulted from homosexual contact, whereas in Africa, the disease is spread primarily through sexual intercourse among heterosexuals.
- Transmission in pregnancy. High-risk mothers include women married to bisexual men or men who have an abnormal blood condition called hemophilia and require blood transfusions, intravenous drug users, and women living in neighborhoods with a high rate of HIV infection among heterosexuals. The chances of transmitting the disease to the child are higher in women in advanced stages of the disease. Breast feeding increases the risk of transmission by 10-20% and is not recommended. The use of zidovudine (AZT) during pregnancy and delivery, however, can decrease the risk of transmission to the baby.
- Exposure to contaminated blood or blood products. With the introduction of blood product screening in the mid-1980s, the incidence of HIV transmission in blood transfusions has dropped to 1 in 100,000.
- Needle sticks among health care professionals. Present studies indicate that the risk of HIV transmission by a needle stick is about 1 in 250. This rate can be decreased if the injured worker is given AZT or triple therapy (HAART), the current standard.
HIV is not transmitted by handshakes or other casual non-sexual contact, coughing or sneezing, or by bloodsucking insects such as mosquitoes.
AIDS in women
AIDS in women is a serious public health concern. Women exposed to HIV infection through heterosexual contact are the most rapidly growing risk group in the United States. The percentage of AIDS cases diagnosed in women has risen from 7% in 1985 to 18% in 1996. For unknown reasons, women with AIDS do not live as long as men with AIDS.
AIDS in children
mothers are at risk. As of 1997, it was estimated that 84% of HIV-positive women are of childbearing age; 41% of them are drug abusers. Between 15-30% of children born to HIV-positive women will be infected with the virus.
AIDS is one of the 10 leading causes of death in children between one and four years of age worldwide. The interval between exposure to HIV and the development of AIDS is shorter in children than in adults. Infants infected with HIV have a 20-30% chance of developing AIDS within a year and dying before age three. In the remainder, AIDS progresses more slowly; the average child patient survives to seven years of age. Some survive into early adolescence.
Causes & symptoms
Because HIV destroys immune system cells, AIDS is a disease that can affect any of the body's major organ systems. HIV attacks the body through three disease processes: immunodeficiency, autoimmunity, and nervous system dysfunction.
Immunodeficiency describes the condition in which the body's immune response is damaged, weakened, or is not functioning properly. In AIDS, immunodeficiency results from the way that the virus binds to a protein called CD4, which is found on certain white blood cells, including helper T cells, macrophages, and monocytes. Once HIV attaches to an immune system cell, it can replicate within the cell and kill the cell. In addition to killing some lymphocytes directly, the AIDS virus disrupts the functioning of other CD4 cells. Because the immune system cells are destroyed, infections and cancers that take advantage of a person's weakened immune system (opportunistic) can develop.
Autoimmunity is a condition in which the body's immune system produces antibodies that work against its own cells. Antibodies are specific proteins produced in response to exposure to a specific, usually foreign, protein or particle called an antigen. In this case, the body produces antibodies that bind to blood platelets that are necessary for proper blood clotting and tissue repair. Once bound, the antibodies mark the platelets for removal from the body, and they are filtered out by the spleen. Some AIDS patients develop a disorder, called immune-related thrombocytopenia purpura (ITP), in which the number of blood platelets drops to abnormally low levels.
The course of AIDS generally progresses through three stages, although not all patients will follow this progression precisely:
Acute retroviral syndrome
Acute retroviral syndrome is a term used to describe a group of symptoms that can resemble mononucleosis and that may be the first sign of HIV infection in 50-70% of all patients and 45-90% of women. The symptoms may include fever, fatigue, muscle aches, loss of appetite, digestive disturbances, weight loss, skin rashes, headache, and chronically swollen lymph nodes (lymphadenopathy). Approximately 25-33% of patients will experience a form of meningitis during this phase, in which the membranes that cover the brain and spinal cord become inflamed. Acute retroviral syndrome develops between one and six weeks after infection and lasts two to four weeks, sometimes up to six weeks. Blood tests during this period will indicate the presence of virus (viremia) and the appearance of the viral p24 antigen in the blood.
After the HIV virus enters a patient's lymph nodes during the acute retroviral syndrome stage, the disease becomes latent for as many as 10 years or more before symptoms of advanced disease develop. During latency, the virus continues to replicate in the lymph nodes, where it may cause one or more of the following conditions.
PERSISTENT GENERALIZED LYMPHADENOPATHY (PGL). Persistent generalized lymphadenopathy, or PGL, is a condition in which HIV continues to produce chronic painless swellings in the lymph nodes during the latency period. The lymph nodes most frequently affected by PGL are those in the areas of the neck, jaw, groin, and armpits. PGL affects between 50-70% of patients during latency.
CONSTITUTIONAL SYMPTOMS. Many patients will develop low-grade fevers, chronic fatigue, and general weakness. HIV also may cause a combination of food
OTHER ORGAN SYSTEMS. At any time during the course of HIV infection, patients may suffer from a yeast infection in the mouth called thrush, open sores or ulcers, or other infections of the mouth; diarrhea and other gastrointestinal symptoms that cause malnutrition and weight loss; diseases of the lungs and kidneys; and degeneration of the nerve fibers in the arms and legs. HIV infection of the nervous system leads to general loss of strength, loss of reflexes, and feelings of numbness or burning sensations in the feet or lower legs.
Late-stage AIDS usually is marked by a sharp decline in the number of CD4+ lymphocytes (a type of white blood cell), followed by a rise in the frequency of opportunistic infections and cancers. Doctors monitor the number and proportion of CD4+ lymphocytes in the patient's blood in order to assess the progression of the disease and the effectiveness of different medications. About 10% of infected individuals never progress to this overt stage of the disease.
OPPORTUNISTIC INFECTIONS. Once the patient's CD4+ lymphocyte count falls below 200 cells/mm3, he or she is at risk for opportunistic infections. The infectious organisms may include:
- Fungi. Fungal infections include a yeast infection of the mouth (candidiasis or thrush) and cryptococcal meningitis.
- Protozoa. The most common parasitic disease associated with AIDS is Pneumocystis carinii pneumonia (PCP). About 70-80% of AIDS patients will have at least one episode of PCP prior to death. PCP is the immediate cause of death in 15-20% of AIDS patients. It is an important measure of a patient's prognosis. Toxoplasmosis is another common infection in AIDS patients that is caused by a protozoan. Other diseases in this category include amebiasis and cryptosporidiosis.
- Mycobacteria. AIDS patients may develop tuberculosis or MAC infections. MAC infections are caused by Mycobacterium avium-intracellulare, and occur in about 40% of AIDS patients.
- Bacteria. AIDS patients are likely to develop bacterial infections of the skin and digestive tract.
- Viruses. AIDS patients are highly vulnerable to cytomegalovirus (CMV), herpes simplex virus (HSV), varicella zoster virus (VZV), and Epstein-Barr virus (EBV) infections. Another virus, JC virus, causes progressive destruction of brain tissue in the brain stem, cerebrum, and cerebellum (multifocal leukoencephalopathy or PML), which is regarded as an AIDS-defining illness by the Centers for Disease Control and Prevention.
|ESTIMATED NUMBER OF ADULTS AND CHILDREN LIVING WITH AIDS/HIV WORLDWIDE AS OF 2001|
|Australia & New Zealand||15,000|
|East Asia & Pacific||1,000,000|
|Eastern Europe & Central Asia||1,000,000|
|North Africa & Middle East||500,000|
|South & Southeast Asia||5,600,000|
AIDS DEMENTIA COMPLEX AND NEUROLOGIC COMPLICATIONS. AIDS dementia complex is a late complication of the disease. It is unclear whether it is caused by the direct effects of the virus on the brain or by intermediate causes. AIDS dementia complex is marked by loss of reasoning ability, loss of memory, inability to concentrate, apathy and loss of initiative, and unsteadiness or weakness in walking. Some patients also develop seizures.
MUSCULOSKELETAL COMPLICATIONS. Patients in late-stage AIDS may develop inflammations of the muscles, particularly in the hip area, and may have arthritis-like pains in the joints.
ORAL SYMPTOMS. Patients may develop a condition called hairy leukoplakia of the tongue. This condition also is regarded by the CDC as an indicator of AIDS. Hairy leukoplakia is a white area of diseased tissue on the tongue that may be flat or slightly raised. It is caused by the Epstein-Barr virus.
AIDS-RELATED CANCERS. Patients with late-stage AIDS may develop Kaposi's sarcoma (KS), a skin tumor that primarily affects homosexual men. KS is the most common AIDS-related malignancy. It is characterized by reddish-purple blotches or patches (brownish in African-Americans) on the skin or in the mouth. About 40% of
Invasive cancer of the cervix is an important diagnostic marker of AIDS in women.
Because HIV infection produces such a wide range of symptoms, the CDC has drawn up a list of 34 conditions regarded as defining AIDS. The physician will use the CDC list to decide whether the patient falls into one of these three groups:
- definitive diagnoses with or without laboratory evidence of HIV infection
- definitive diagnoses with laboratory evidence of HIV infection
- presumptive diagnoses with laboratory evidence of HIV infection
Almost all symptoms of AIDS can occur with other diseases. The general physical examination may range from normal findings to symptoms that are closely associated with AIDS. These symptoms are hairy leukoplakia of the tongue and Kaposi's sarcoma. When the doctor examines the patient, he or she will look for the overall pattern of symptoms rather than any one finding.
Laboratory tests for HIV infection
BLOOD TESTS (SEROLOGY). The first blood test for AIDS was developed in 1985. At present, patients who are being tested for HIV infection usually are given an enzyme-linked immunosorbent assay (ELISA) test for the presence of HIV antibody in their blood. Positive ELISA results then are tested with a Western blot or immunofluorescence (IFA) assay for confirmation. The combination of the ELISA and Western blot tests is more than 99.9% accurate in detecting HIV infection within four to eight weeks following exposure. The polymerase chain reaction (PCR) test can be used to detect the presence of viral nucleic acids in the very small number of HIV patients who have false-negative results on the ELISA and Western blot tests. In 2003, a one-step test that was quicker and cheaper was shown effective for detecting HIV in the physician office setting. However, further research was ongoing as to its effectiveness in replacing current tests as a first check for HIV.
OTHER LABORATORY TESTS. In addition to diagnostic blood tests, there are other blood tests that are used to track the course of AIDS. These include blood counts, viral load tests, p24 antigen assays, and measurements of β2-microglobulin (β2M).
Doctors will use a wide variety of tests to diagnose the presence of opportunistic infections, cancers, or other disease conditions in AIDS patients. Tissue biopsies, samples of cerebrospinal fluid, and sophisticated imaging techniques, such as magnetic resonance imaging (MRI) and computed tomography scans (CT) are used to diagnose AIDS-related cancers, some opportunistic infections, damage to the central nervous system, and wasting of the muscles. Urine and stool samples are used to diagnose infections caused by parasites. AIDS patients also are given blood tests for syphilis and other sexually transmitted diseases.
Diagnosis in children
Diagnostic blood testing in children older than 18 months is similar to adult testing, with ELISA screening confirmed by Western blot. Younger infants can be diagnosed by direct culture of the HIV virus, PCR testing, and p24 antigen testing.
In terms of symptoms, children are less likely than adults to have an early acute syndrome. They are, however, likely to have delayed growth, a history of frequent illness, recurrent ear infections, a low blood cell count, failure to gain weight, and unexplained fevers. Children with AIDS are more likely to develop bacterial infections, inflammation of the lungs, and AIDS-related brain disorders than are HIV-positive adults.
AIDS patients turn to alternative medicine when conventional treatments are ineffective, and to supplement conventional treatment, reduce disease symptoms, counteract drug effects, and improve quality of life. Because alternative medicines may interact with conventional medicines, it is important for the patient to inform his or her doctor of all treatments being used.
A report released in 2003 showed trends in increased use of alternative medicine among HIV-positive individuals. Based on 1997 figures, the study reported that 79% of those seeking alternative therapy to help with AIDS treatment or symptom relief were men and 63% were women. The types of therapies they used most were relaxation techniques, massage, chiropractic care, self-help groups, commercial diets, and acupuncture.
- Lauric oils (coconut oil) are used by the body to make monolaurin, which inactivates HIV.
- Selenium deficiency increases the risk of death due to AIDS-related illness. One study found that 250 micrograms of selenomethionin daily for one year showed no improvement in CD4 cell counts or disease symptoms. Greater than 1,000 micrograms daily is toxic.
- Vitamin C has antioxidant and antiretroviral activities. One study found that treatment caused a trend to decrease viral load.
- DHEA (dehydroepiandrosterone) is commonly used by AIDS patients to counteract wasting. One study found that DHEA had no effect on lymphocytes or p24 antigen levels. However, a 2002 study found that it was associated with a significant increase in measures that indicate mental health improvement.
- Vitamin A deficiency is associated with increased mortality. One study of pregnant women with AIDS found that 5000 IU of vitamin A daily led to stabilized viral load as compared to a placebo group. Another study found that 60 mg of vitamin A had no effect on CD4 cells or viral load. Vitamin A has been associated with faster disease progression. Excessive vitamin A during pregnancy can cause birth defects.
- Beta-carotene supplementation for AIDS is controversial as studies have shown both beneficial and detrimental effects. Beta-carotene supplementation has led to elevation in white blood cell counts and changes in the CD4 cell count. Some studies have found that beta-carotene supplementation led to an increase in deaths due to cancer and heart disease.
Naturopathic doctors often recommend the following supplements for AIDS:
Herbals and Chinese medicine
One small study of the effectiveness of Chinese herbal treatment in AIDS showed promise. AIDS patients took a tablet that contained 31 herbs that was based on the formulas Enhance and Clear Heat. Disease symptoms were reduced in the herbal treatment group as compared to the placebo group.
Herbals used in treating AIDS include:
- Maitake mushroom extract. Recommended dose is 10 drops twice daily
- Licorice (Glycyrrhiza glabra) solid extract. Recommended dose is one quarter to one half teaspoon twice daily
- Boxwood extract (SPV-30) has antiviral activity. Recommended dose is one capsule thrice daily.
- Garlic concentrate (Allicin) helped reduce bowel movements, stabilized or increased body weight, or cured Cryptosporidium parvum infection in affected AIDS patients. However, a 2002 National Institutes of Health study cautioned that garlic supplements could reduce levels of a protease inhibitor that is used to treat AIDS patients, so patients should discuss using garlic supplements with their physicians.
- Tea tree oil (Malaleuca) improves or cures infection of the mouth by the yeast Candida. Tea tree oil is available as soap, dental floss, toothpick, and mouthwash.
- Marijuana is used to treat wasting. Studies have found that patients who use marijuana had increased food intake and weight gain. The active ingredient delta-9-tetrahydrocannabinol is licensed for treating AIDS wasting.
Psychotherapy and stress reduction
Many therapies that are directed at improving mental state can have a direct impact on disease severity and quality of life. The effectiveness of many have been proven in clinical studies. These include:
- stress management training
- cognitive therapy
- aerobic exercise
Treatment for AIDS covers four categories:
In recent years researchers have developed drugs that suppress HIV replication. The drugs are used in combination with one another and fall into four classes:
- Nucleoside reverse transcriptase inhibitors. These drugs work by interfering with the action of HIV reverse transcriptase, thus ending the virus replication process. These drugs include zidovudine (sometimes called Zidovudine or AZT, trade name Retrovir), didanosine (ddi, Videx), emtricitabine (FTC, Emtriva), zalcitabine (ddC, Hivid), stavudine (d4T, Zerit), abacavir (Ziagen), tenofovir (df, Viread), and lamivudine (3TC, Epivir).
- Protease inhibitors. Protease inhibitors are effective against HIV strains that have developed resistance to nucleoside analogues, and often are used in combination with them. These compounds include saquinavir (Fortovase), ritonavir (Norvir), indinavir (Crixivan), amprenavir (Agenerase), lopinavir plus ritonavir (Reyataz), and nelfinavir (Viracept).
- Non-nucleoside reverse transcriptase inhibitors. This is a newer class of antiretroviral agents. Three are available, nevirapine (Viramune), efavirenz (Sustiva), and delavirdine (Rescriptor).
- Fusion inhibitors. These drugs are less common, expensive and difficult to use. They block infection early by preventing HIV from fusing with and entering a human cell. This class includes only one compound: Enfuvirtide (Fuzeon).
Treatment guidelines for these agents are in constant change as new medications are developed and introduced. In mid-2003, the U.S. Department of Health and Human Services revised its guidelines for the use of these agents to help clinicians better choose the best combinations. The new guidelines offer a list of suggested combination regimens classified as either "preferred" or "alternative".
Treatment of opportunistic infections and malignancies
Most AIDS patients require complex long-term treatment with medications for infectious diseases. This treatment often is complicated by the development of resistance in the disease organisms. AIDS-related malignancies in the central nervous system usually are treated with radiation therapy. Cancers elsewhere in the body are treated with chemotherapy.
Prophylactic treatment for opportunistic infections
Prophylactic treatment is treatment that is given to prevent disease. AIDS patients with a history of Pneumocystis pneumonia; with CD4+ counts below 200 cells/mm3 or 14% of lymphocytes; weight loss; or thrush should be given prophylactic medications. The three drugs given are trimethoprim-sulfamethoxazole, dapsone, or pentamidine in aerosol form.
STIMULATION OF BLOOD CELL PRODUCTION. Because many patients with AIDS suffer from abnormally low levels of both red and white blood cells, they may be given medications to stimulate blood cell production. Epoetin alfa (erythropoietin) may be given to anemic patients. Patients with low white blood cell counts may be given filgrastim or sargramostim.
Treatment in women
Treatment of pregnant women with HIV is particularly important because antiretroviral therapy has been shown to reduce transmission to the infant by 65%.
At the present time, there is no cure for AIDS. Treatment stresses aggressive combination drug therapy when possible. The use of multi-drug therapies has significantly reduced the number of U.S. deaths resulting from AIDS. The potential exists to possibly prolong life indefinitely using these and other drug therapies to boost the immune system, keep the virus from replicating, and ward off opportunistic infections and malignancies.
Prognosis after the latency period depends on the patient's specific symptoms and the organ systems affected by the disease. Patients with AIDS-related lymphomas of the central nervous system die within two to three months of diagnosis; those with systemic lymphomas may survive for eight to ten months. In America, the successful treatment of AIDS patients with HAART has actually led to a growing number of people living with HIV. About 25,000 infected people per year are added to the list of HIV-infected Americans.
However, not only does HAART and other treatment prolong AIDS patients' lives, it has led to some improvement in quality of life too. A recent study shows that HAART therapy substantially reduces risk of AIDS-related pneumonia (PCP), although PCP still remains the most common AIDS-defining illness among opportunistic infections. Other recent studies show that these protease inhibitors may result in high cholesterol and put AIDS patients at eventual risk for heart disease. Further research must be done, since long-term effects of HAART treatment are just now being studied. Most clinicians would say the benefits outweigh the risks anyway.
As of 2000, there is no vaccine effective against AIDS. Several vaccines to prevent initial HIV infection and disease progression are being tested. In 2002, reports showed a new "library" vaccine showed potential. The vaccine is composed of up to 32 HIV gene fragments that can induce a number of immune responses. In the same year, the British government worked with five African countries in a trial to find an effective gel that would protect women against HIV during sex. The study
Precautions to take to prevent the spread of AIDS include:
- Monogamy and practicing safe sex. Besides avoiding the risk of HIV infection, condoms are successful in preventing other sexually transmitted diseases and unwanted pregnancies.
- Avoiding needle sharing among intravenous drug users.
- Although blood and blood products are carefully monitored, those individuals who are planning to undergo major surgery may wish to donate blood ahead of time to prevent a risk of infection from a blood transfusion.
- Healthcare professionals should wear gloves and masks when handling body fluids and avoid needle-stick injuries.
- A person who suspects that he or she may have become infected should get tested. If treated aggressively and early, the development of AIDS can sometimes be postponed indefinitely. If HIV infection is confirmed, it also is vital to inform sexual partners.
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Teresa G. Odle
Table Of Contents
- Risk factors
- AIDS in women
- AIDS in children
- Causes & symptoms
- Acute retroviral syndrome
- Latency period
- Late-stage AIDS
- Physical findings
- Laboratory tests for HIV infection
- Diagnosis in children
- Herbals and Chinese medicine
- Psychotherapy and stress reduction
- Allopathic treatment
- Antiretroviral treatment
- Treatment of opportunistic infections and malignancies
- Prophylactic treatment for opportunistic infections
- Treatment in women
- Expected results