Aids Simplified

Due to the difficulty in treating HIV infection, preventing infection isa key aim in controlling the AIDS epidemic, with health organizations promoting

safesex

and

needle-exchange programmes

in attempts to slow the spread of the virus.

Symptoms

A generalized graph of the relationship between HIV copies (viral load) and CD4 counts overthe average course of untreated HIV infection; any particular individual's disease course mayvary considerably. CD4

+

T Lymphocyte count (cells/mm³) HIV RNA copies per mL of plasma The symptoms of AIDS are primarily the result of conditions that do not normally develop inindividuals with healthyimmune systems. Most of these conditions are infections causedbybacteria,viruses,fungiandparasitesthat are normally controlled by the elements of the immune system that HIV damages.Opportunistic infectionsare common in people withAIDS.

[10]

HIV affects nearly everyorgan system. People with AIDS also have an increased riskof developing various cancers such asKaposi's sarcoma,cervical cancerand cancers of the immune system known aslymphomas. Additionally, people with AIDS often have systemicsymptoms of infection likefevers,sweats(particularly at night), swollen glands, chills, weakness, andweight loss.

[11][12]

The specific opportunistic infections that AIDS patientsdevelop depend in part on the prevalence of these infections in the geographic area in whichthe patient lives.Main symptoms of AIDS.

Pulmonary infections

X-ray of Pneumocystis

jirovecii caused pneumonia. There is increased white (opacity) in thelower lungs on both sides, characteristic of

Pneumocystis

pneumoniaPneumocystis pneumonia(originally known as

Pneumocystis carinii

pneumonia, and stillabbreviated as PCP, which now stands for

P

neumo

c

ystis

p

neumonia) is relatively rare inhealthy,immunocompetentpeople, but common among HIV-infected individuals. It is causedbyPneumocystis

jirovecii . Before the advent of effective diagnosis, treatment androutineprophylaxisin Western countries, it was a common immediate cause of death. Indeveloping countries, it is still one of the first indications of AIDS in untested individuals,although it does not generally occur unless the CD4 count is less than 200 cells per µL of blood.

[13]

Tuberculosis(TB) is unique among infections associated with HIV because it is transmissible toimmunocompetent people via the respiratory route, is easily treatable once identified, mayoccur in early-stage HIV disease, and is preventable with drug therapy. However,multidrugresistanceis a potentially serious problem. Even though its incidence has declined because of the use of directly observed therapy and other improved practices in Western countries, this isnot the case in developing countries where HIV is most prevalent. In early-stage HIV infection(CD4 count >300 cells per µL), TB typically presents as a pulmonary disease. In advanced HIV

infection, TB often presents atypically with extrapulmonary (systemic) disease a commonfeature. Symptoms are usually constitutional and are not localized to one particular site, oftenaffectingbone marrow,bone, urinary andgastrointestinal tracts,liver, regionallymph nodes, and thecentral nervous system.

[14]

Gastrointestinal infections

Esophagitisis an inflammation of the lining of the lower end of theesophagus(gullet or swallowing tube leading to thestomach). In HIV infected individuals, this is normally due tofungal (candidiasis) or viral (herpes simplex-1orcytomegalovirus) infections. In rare cases, it could be due tomycobacteria.

[15]

Unexplained chronicdiarrheain HIV infection is due to many possible causes, includingcommon bacterial (

,

,

or

) and parasitic infections;and uncommon opportunistic infections suchascryptosporidiosis,microsporidiosis,

Mycobacterium avium

complex (MAC) andviruses,

[16]

astrovirus,adenovirus,rotavirusandcytomegalovirus, (the latter as a course of colitis). In some cases, diarrhea may be a side effect of several drugs used to treat HIV, or itmay simply accompany HIV infection, particularly during primary HIV infection. It may also bea side effect of antibioticsused to treat bacterial causes of diarrhea (common for

Clostridiumdifficile

). In the later stages of HIV infection, diarrhea is thought to be a reflection of changesin the way theintestinal tractabsorbs nutrients, and may be an important component of HIV-relatedwasting.

[17]

Neurological and psychiatric involvement

HIV infection may lead to a variety of neuropsychiatricsequelae, either by infection of thenow susceptible nervous system by organisms, or as a direct consequence of the illness itself. Toxoplasmosisis a disease caused by the single-celledparasitecalled

Toxoplasma gondii

; itusually infects the brain, causing toxoplasmaencephalitis, but it can also infect and causedisease in theeyesand lungs.

[18]

Cryptococcal meningitis is an infection of themeninx(themembrane covering the brain andspinal cord) by the fungus

Cryptococcus neoformans

. It cancause fevers,headache,fatigue,nausea, andvomiting. Patients may also developseizuresand confusion; left untreated, it can be lethal.Progressive multifocal leukoencephalopathy(PML) is ademyelinating disease, in which the gradual destruction of themyelinsheath covering theaxonsof nerve cells impairs the transmission of nerve impulses. It is caused by a virus called JC viruswhich occurs in 70% of the population inlatentform, causing disease only when the immune system has beenseverely weakened, as is the case for AIDS patients. It progresses rapidly, usually causingdeath within months of diagnosis.

[19]

AIDS dementia complex(ADC) is a metabolicencephalopathyinduced by HIV infection and fueled by immune activation of HIV infected brainmacrophagesandmicroglia. These cells are productively infected by HIV and secreteneurotoxinsof both host and viral origin.

[20]

Specificneurological impairments are manifested by cognitive, behavioral, and motor abnormalitiesthat occur after years of HIV infection and are associated with low CD4

+

T cell levels and highplasma viral loads. Prevalence is 10–20% in Western countries

[21]

but only 1–2% of HIVinfections in India.

[22][23]

This difference is possibly due to the HIV subtype in India. AIDS relatedmania is sometimes seen in patients with advanced HIV illness; it presents with moreirritability and cognitive impairment and less euphoria than amanic episodeassociated withtruebipolar disorder. Unlike the latter condition, it may have a more chronic course. Thissyndrome is less often seen with the advent of multi-drug therapy.

Tumors and malignancies

Kaposi's sarcomaPatients with HIV infection have substantially increased incidence of severalcancers. This isprimarily due to co-infection with anoncogenic DNA virus, especiallyEpstein-Barr virus(EBV),Kaposi's sarcoma-associated herpesvirus(KSHV), and humanpapillomavirus(HPV).

[24][25]

Kaposi's sarcoma (KS) is the most common tumor in HIV-infected patients. The appearance of this tumor in young homosexual men in 1981 was one of the first signals of the AIDSepidemic. Caused by agammaherpesvirus calledKaposi's sarcoma-associated herpes virus(KSHV), it often appears as purplishnoduleson the skin, but can affect other organs, especially themouth, gastrointestinal tract, and lungs.High-gradeB cell lymphomassuch asBurkitt's lymphoma, Burkitt's-like lymphoma, diffuse large B-cell lymphoma (DLBCL), andprimary central nervous system lymphomapresent moreoften in HIV-infected patients. These particular cancers often foreshadow a poor prognosis. In

some cases these lymphomas are AIDS-defining.Epstein-Barr virus(EBV) or KSHV cause manyof these lymphomas.Cervical cancerin HIV-infected women is considered AIDS-defining. It is caused byhumanpapillomavirus(HPV).

[26]

In addition to the AIDS-defining tumors listed above, HIV-infected patients are at increasedrisk of certain other tumors, such asHodgkin's diseaseandanalandrectal carcinomas. However, the incidence of many common tumors, such asbreast cancerorcolon cancer, does not increase in HIV-infected patients. In areas whereHAARTis extensively used to treat AIDS,the incidence of many AIDS-related malignancies has decreased, but at the same timemalignant cancers overall have become the most common cause of death of HIV-infectedpatients.

[27]

Other opportunistic infections

AIDS patients often develop opportunistic infections that present with non-specific symptoms,especiallylow-grade feversand weight loss. These include infection with

Mycobacteriumavium-intracellulare

andcytomegalovirus(CMV). CMV can cause colitis, as described above,andCMV retinitiscan causeblindness.Penicilliosisdue to

Penicillium marneffei

is now the thirdmost common opportunistic infection (after extrapulmonary tuberculosis andcryptococcosis)in HIV-positive individuals within the endemic area of Southeast Asia.

[28]

CauseAIDS is the most severe acceleration of infectionwith HIV. HIV is aretrovirusthat primarily infects vital organs of the humanimmune systemsuch asCD4

+

T cells(a subset of Tcells),macrophagesanddendritic cells. It directly and indirectly destroys CD4

+

T cells.

[29]

OnceHIV has killed so many CD4

+

T cells that there are fewer than 200 of these cellspermicroliter(µL) of blood,cellular immunityis lost.AcuteHIV infection progresses over time to clinical latent HIV infection and then to earlysymptomaticHIV infection and later to AIDS,which is identified either on the basis of the amount of CD4

+

T cells remaining in the blood,and/or the presence of certain infections, as noted above.

[30]

In the absence of antiretroviral therapy, themedian time of progression from HIV infection to AIDSis nine to ten years, and the median survival time after developing AIDS is only 9.2months.

[31]

However, the rate of clinical disease progression varies widely between individuals,from two weeks up to 20 years. Many factors affect the rate of progression. These includefactors that influence the body's ability to defend against HIV such as the infected person'sgeneral immune function.

[32][33]

Older people have weaker immune systems, and thereforehave a greater risk of rapid disease progression than younger people. Poor access tohealthcareand the existence of coexisting infections such astuberculosisalso may predispose people to faster disease progression.

[31][34][35]

The infected person'sgenetic inheritanceplaysan important role and some people areresistantto certain strains of HIV. An example of this ispeople with thehomozygous CCR5-Δ32variation are resistant to infection with certainstrainsof HIV.

[

HIV is genetically variable and exists as different strains, which causedifferent rates of clinical disease progression.

Sexual transmission

Sexual transmission occurs with the contact between sexual secretions of one person with therectal, genital or oralmucous membranesof another. Unprotected receptive sexual acts areriskier than unprotected insertive sexual acts, and the risk for transmitting HIV throughunprotected anal intercourse is greater than the risk from vaginal intercourse or oral sex.However, oral sex is not entirely safe, as HIV can be transmitted through both insertive andreceptive oral sex.

[40][41]

Sexual assault greatly increases the risk of HIV transmission asprotection is rarely employed and physical trauma to the vagina frequently occurs, facilitatingthe transmission of HIV.

[42]

Othersexually transmitted infections(STI) increase the risk of HIV transmission and infection,because they cause the disruption of the normalepithelialbarrier by genitalulcerationand/or microulceration; and by accumulation of pools of HIV-susceptible or HIV-infected cells(lymphocytesandmacrophages) in semen and vaginal secretions. Epidemiological studies from sub-Saharan Africa,EuropeandNorth Americasuggest that genital ulcers, such as those caused bysyphilisand/orchancroid, increase the risk of becoming infected with HIV by about four-fold. There is also a significant although lesser increase in risk from STIs suchasgonorrhea,Chlamydial infectionandtrichomoniasis, which all cause local accumulations of lymphocytes and macrophages.

[43]

Transmission of HIV depends on the infectiousness of theindex caseand the susceptibility of the uninfected partner. Infectivity seems to vary during the course of illness and is not

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