HIV infection

There are several symptoms of HIV infection which vary from person to person and also as per the stage of the infection. The three stages of HIV infection are:

Stage 1: Acute HIV Infection

It is estimated that 50-70% of individuals with HIV infection experience a flu-like illness within 2 to 4 weeks after primary infection. This is known as primary or acute HIV infection and lasts for weeks. Some people do not have any symptoms during this phase. The symptoms can include:

• Fever
• Chills
• Rashes
• Headache
• Swollen lymph glands, mainly on the neck
• Night sweats
• Mouth ulcers or genital ulcers
• Joint pain
• Fatigue

Stage 2: Clinical Latency

In this stage, the virus is multiplying, but at a very low level. There are no detectable signs and symptoms in this stage. This stage is called chronic HIV infection. Although the length of time from initial infection to the development of clinical disease varies greatly, the median time for untreated patients is approximately 10 years. The rate of ongoing progression is directly correlated with HIV RNA levels. Patients with high levels of HIV RNA in plasma progress to symptomatic disease faster than those with low levels of HIV RNA. The transmission of HIV is highest during this stage if viral load is detected in the blood. There is a risk of transmitting HIV to sexual partners.

Stage 3: AIDS

If a person has HIV and is not on treatment, the virus will gradually weaken the immune system and progress to AIDS. A diagnosis of AIDS is made in any individual age 6 years and older with HIV infection and a CD4+ T cell count less than 200 per microliter, and in anyone with HIV infection who develops one of the HIV-associated diseases considered indicative of a severe defect in cell-mediated immunity. Symptoms of AIDS include:

• Pneumonia
• Sores of the mouth and anus
• Extreme tiredness
• Rapid weight loss
• Recurring fever
• Memory loss and depression

Each of these symptoms can lead to another illness. Many of the severe symptoms of HIV are opportunistic infections that occur when the immune system weakens.

The human immunodeficiency virus belongs to the family of human retroviruses and the subfamily of lentiviruses; it causes AIDS. HIV is a sexually transmitted disease (STD). AIDS is caused by HIV. HIV is a virus that attacks the immune system of the body. As HIV progressively damages the immune cells, the body's immunity becomes compromised, making it susceptible to many opportunistic infections. The most advanced stage of HIV infection is called AIDS, which can take many years to develop.

The main causes of HIV include:

• Sexual contact: The most frequent mode of transmission is through unprotected vaginal or anal sex.
• Blood transfusion: There is a risk of contracting the virus through contaminated blood transfusions.
• Sharing infected needles: HIV can be transmitted by sharing needles and syringes that are infected.
• From mother to child: The virus can be passed from an expectant mother to her child during pregnancy, childbirth, or breastfeeding.
• Through body fluids: HIV can spread through various body fluids, including blood, semen, vaginal fluid, breast milk, amniotic fluid, and cerebrospinal fluid.

A risk factor increases the chances of getting the disease. Certain lifestyle factors are related to HIV infection, and by changing them, the risk of acquiring HIV gradually lowers. The most common risk factors include:

• Having unprotected sex: Most people contract HIV through unprotected sex. During intercourse, the rectum, mouth, and genitals can allow the virus to enter the body. To avoid this, protection should be used. The use of condoms significantly lowers the risk of sexually transmitted diseases. The chances are also higher for men who have sex with men and for those with multiple partners.
• Drug use: Sharing needles increases the risk of HIV transmission. Even a small amount of blood can be sufficient to transmit the virus.
• Certain health problems: Having specific sexually transmitted diseases can elevate the risk of HIV. Common examples include gonorrhea, warts, syphilis, and genital herpes.
• Blood products: Blood banks do not routinely test for HIV. The infection can be transmitted to recipients during a blood transfusion.
• Having certain professions: Working in environments where you come into contact with bodily fluids and blood samples increases the risk of HIV. This includes healthcare professionals and laboratory workers.

The risk factors for mother-to-child transmission of HIV via breastfeeding include:

• Detectable levels of HIV in breast milk
• The presence of mastitis (inflammation in breast tissues)
• Lower maternal CD4+ T cell counts
• Maternal Vitamin A deficiency

HIV testing is conducted to detect the Human Immunodeficiency Virus in serum, saliva, and urine. The only definitive way to determine if a person is infected with HIV is through an HIV test. Symptoms of HIV may not manifest for many years. Anyone who suspects they may have HIV should seek testing.

Clinical History

The doctor will inquire about your symptoms and health history. A physical examination is performed to identify specific risks that may increase your chances of infection. If the doctor suspects HIV, confirmatory tests are necessary to initiate treatment as soon as possible.

Laboratory Tests (Nucleic Acid Testing and Antigen/Antibody Tests)

The following tests can be conducted to confirm if a person is HIV positive or negative:

• HIV 1 and HIV 2 Antibody Test: There are two types of HIV: HIV-1 and HIV-2. HIV-1 is more prevalent among individuals at higher risk for AIDS, while HIV-2 is primarily found in West Africa. This test checks for the amount of virus and p24 antigen in the blood, which typically increases during the first week of infection.
• CD4 Count: CD4 cells are a type of white blood cell specifically targeted and destroyed by HIV. A healthy individual has a CD4 count of up to 1000. The CD4 count correlates with the patient's immunity levels; a higher CD4 count indicates better immunity. However, when HIV progresses to AIDS, the CD4 count falls below 200.
• Enzyme-Linked Immunosorbent Assay (ELISA): The ELISA test is a blood antibody test that detects proteins produced during HIV infection. It is a widely used method for HIV detection and is also referred to as an enzyme immunoassay.
• Western Blot: A positive ELISA test is typically followed by a Western blot, which serves as a confirmatory diagnostic test for AIDS.
• Rapid Antibody Screening: This test is conducted using blood from a finger prick or oral fluids, with results available within 30 minutes.
• Rapid Antigen/Antibody Test: This immunoassay is used for screening and produces results within 30 minutes. It utilizes blood or oral fluids to detect antibodies for HIV. All positive immunoassay results require further follow-up with a doctor.
• Oral Fluid Antibody Self-Test: The OraQuick in-home HIV test is a self-administered over-the-counter test that uses oral fluid to check for antibodies to HIV-1 and HIV-2, the viruses that cause AIDS.

Note: No HIV test can detect the virus immediately after infection. The interval between acquiring the infection and when a test can reliably indicate the presence of the virus is known as the Window Period. This period varies among individuals and depends on the type of test used to detect HIV.

A nucleic acid test usually indicates HIV infection 10 to 33 days after exposure.

An antigen/antibody test performed in a laboratory detects HIV infection 18 to 45 days after exposure. A rapid finger prick test may take 18 to 90 days for accurate results.

Antibody tests typically require 23 to 90 days to detect an infection.

There is no vaccine to prevent HIV infection, and no cure for HIV has been discovered to date. To help prevent the spread of HIV, the following measures are recommended:

• Spreading awareness among the masses.
• Safe blood transfusion from authorized and accredited blood banks.
• Get tested for HIV: Before engaging in sexual activity, get tested and discuss your status with your partner.
• Use of condoms: Condoms provide protection against HIV and many sexually transmitted infections (STIs). It is crucial that condoms are put on before any sexual contact occurs between the vagina, penis, mouth, or anus.
• Don’t share syringes and needles: Always use sterile drug injection equipment and water, and never share them with others.
• Limit the number of sexual partners: The likelihood of having STIs increases when having a partner who is HIV-positive.
• Get tested and treated for STDs: Having a sexually transmitted disease increases the risk of acquiring HIV or transmitting it to others.
• HIV prevention medicine: If you are HIV-negative, consider taking pre-exposure prophylaxis (PrEP) to reduce the risk of HIV. PrEP is available for individuals at higher risk of HIV infection, particularly those with an HIV-positive partner. A tablet is typically taken before sexual activity and potential exposure to HIV.
• Prevention of mother-to-child transmission of HIV: Pregnant women with HIV should take HIV medications for their health and to prevent transmission of HIV from mother to child.

There is no cure for HIV as of now, but there are very effective treatments that enable most people with the virus to live a healthy and long life.

A. Antiretroviral therapy (ART)

ART reduces HIV-related morbidity at all stages of HIV infection and transmission. It suppresses viral load, maintains the CD4 count, prevents AIDS, and prolongs survival. Healthcare providers play a crucial role in helping patients initiate ART, leading to viral load suppression. Most people take daily HIV treatment to achieve an undetectable viral load within six months of starting treatment. Different classes of ART include:

• Entry inhibitors: These work by blocking the entry of the virus into human cells. Common examples include:
  • Maraviroc
  • Enfuvirtide
  • Ibalizumab
  • Fostemsavir
• Integrase inhibitors: This class of antiretroviral drugs prevents HIV from inserting its genetic code into the DNA of an infected individual. They block the enzyme integrase that HIV requires to replicate. Common side effects include nausea, headache, vomiting, fatigue, nasal infection, and throat infection. Examples include:
  • Isentress
  • Raltegravir
  • Dolutegravir
  • Carbotegravir
  • Abacavir
• Protease inhibitors: These HIV antiviral drugs break down structural proteins necessary for the assembly and morphogenesis of virus particles. They block the protease enzyme, preventing viral replication. Examples include:
  • Indinavir
  • Ritonavir
  • Atazanavir
• Fusion inhibitors: These work on host CD4 cells to prevent HIV from entering a cell. They bind to the envelope protein of the virus, blocking fusion with host CD4 cells. Enfuvirtide is the commonly used medication in this category.

B. Nucleoside reverse transcriptase inhibitors (NRTIs)

NRTIs are active inhibitors of reverse transcriptase in retroviruses. They all share the same mechanism of action but have different activation processes. A major side effect is mitochondrial dysfunction, leading to conditions such as cardiomyopathy, bone marrow suppression, and mitochondrial diseases. Examples include:

• Lamivudine
• Didanosine
• Stavudine
• Zidovudine
• Emtricitabine
• Tenofovir

C. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

NNRTIs are a therapeutic class of compounds used in combination with antiretroviral drugs to treat HIV-1 infection. They block HIV-1 infection by preventing reverse transcriptase from completing the reverse transcription of the single-stranded RNA genome into DNA. Examples include:

• Efavirenz
• Nevirapine
• Etravirine

D. Multi-drug combination

This therapy combines two or more different classes of drugs, providing a strategy against multidrug resistance. It offers potential benefits such as broad-spectrum efficacy, greater potency than monotherapy, and a reduction in the number of resistant organisms. Common combinations include:

• Dolutegravir + Tenofovir + Emtricitabine
• Raltegravir + Tenofovir + Emtricitabine

Living with someone who has HIV is a life-changing experience for both the individual and their family. HIV symptoms vary from person to person, and therefore, the care required also varies. However, a few tips can help in providing care for someone with HIV.

• Talk and understand the situation: Be available for open and honest conversations about HIV. Engage in activities together as you did before the diagnosis. Make them feel like the same person and help them realize that they matter.
• Listen: Receiving an HIV diagnosis is life-changing news. Listen to your loved ones and reassure them that it is a manageable health condition.
• Learn: Educate yourself about HIV, including its transmission and treatment. Understanding HIV is a significant step in providing support to your family member.
• Encourage treatment: Starting HIV treatment early, adhering to the treatment, and staying with the caregiver helps control the viral load and prevents HIV infection from progressing to AIDS.
• Support medication adherence: HIV patients must adhere to their medication. Assist them in creating a routine and following it.
• Join HIV support groups: Connecting with others facing similar challenges can help boost morale. Several organizations in India support people with HIV and encourage them to engage with other patients in a safe and supportive environment.

If left untreated, HIV may severely hamper a patient’s life and can cause various complications such as:

1. HIV does not directly invade the neurons but infects the glial cells that support neurons. HIV triggers inflammation that leads to damage to the brain and spinal cord. Some common symptoms include:
   • Inability to concentrate
   • Headache
   • Behavioral changes
   • Anxiety and depression
   • Lack of coordination and walking
2. HIV infection can cause the shrinking of the brain involved in learning and information processing.
3. Some nervous system complications that occur as a result of HIV infection and drugs include pain, seizures, stroke, vision loss, and coma.
4. In children, HIV infection can lead to developmental delays, nerve pain, slow growth, eye problems, and brain lesions.
5. HIV-associated dementia occurs in the most advanced stages of infection, characterized by a decline in cognitive functions, concentration, memory, and slowing of motor functions.
6. Damage to the peripheral nerves results in progressive weakness and loss of sensation in the arms and legs.
7. Cardiomyopathy, or chronic disease of the heart muscle, can occur during stage IV infection and may result in heart failure.
8. Hepatobiliary diseases, a heterogeneous group of diseases of the liver, bile ducts, and/or gallbladder, commonly occur in HIV patients. These include granulomatous hepatitis and AIDS cholangiopathy.
9. Diseases of the kidney and urinary tract: HIV-associated nephropathy is observed in the majority of patients.
10. AIDS-associated arthropathy: This syndrome is characterized by joint disorders such as subacute oligoarticular arthritis, developing over a period of 1-6 weeks and lasting up to 6 months.
11. Higher risk of genitourinary infections is seen in patients with HIV infection.
12. Immune reconstitution inflammatory syndrome (IRIS): This condition starts following the initiation of ART, with a worsening of pre-existing, untreated, or partially treated opportunistic infections.

Many people use alternative health treatments in addition to medical treatment. Some alternative therapies include:

• Physical therapies
  Physical and body therapies include activities such as yoga, massage, and aromatherapy, promoting healing of the body.
• Yoga: A set of exercises that improve fitness, reduce stress, and increase flexibility. Many people, including those with HIV, use yoga to relax.
• Massage: An excellent way to reduce stress, muscle and back pain, headaches, and soreness.
• Acupuncture: Involves inserting tiny needles into specific areas to treat symptoms like nausea, fatigue, and neuropathy.
• Aromatherapy: Based on the idea that certain smells can influence mood and thoughts, used to manage stress and fatigue.
• Relaxation therapies
  Relaxation therapies such as meditation and visualization can promote overall health and well-being.
• Meditation: Helps individuals relax and calm their minds.
• Visualization: A technique that aids in relaxation and reduces anxiety.
• Herbal medicines
  Herbal medicines are derived from plants, roots, leaves, and flowers, functioning similarly to standard medicines. While they can alleviate symptoms, there is currently no cure.

Taking care of yourself when living with HIV:

• Taking antiretroviral treatment (ART) for HIV: If you’ve been diagnosed with HIV, start treatment as soon as possible. ART is not a cure for HIV, but it keeps the virus under control, protecting your immune system so that you can stay healthy and live a long life.
• Adopt positive healthy living with an appropriate balanced diet: HIV infection weakens the immune system. For longevity and a productive life, individuals need to take special care of their health and well-being. It is important to eat the right amount of food to maintain weight and include a variety of foods from the five food groups: fruits, vegetables, grains, protein foods, and dairy.
• Exercising regularly: A healthy diet and regular exercise are essential to boost your immunity along with medication. Although there is no cure for HIV infection, taking antiretroviral therapy (ART) and exercising regularly can help people live a healthy and fulfilling life for many years.
• Avoid excessive alcohol or drug use: Consumption of alcohol can damage the liver, which is crucial for processing anti-HIV drugs. It is recommended to keep alcohol consumption within the suggested limits. Heavy drinking and recreational drug use can weaken your immune system, making it harder for your body to recover from infections.
• Managing stress and getting support: Stress-management techniques such as yoga, meditation, cognitive restructuring, coping skills training, and interpersonal-skills training may help reduce anxiety, depression, and social isolation in individuals living with HIV by lowering physical tension and increasing a sense of control and self-efficacy.
• HIV and pregnancy: Women living with HIV who become pregnant or acquire the virus during pregnancy face risks of both maternal and perinatal morbidity and mortality, especially if the virus is poorly controlled. There is a risk of transmission to the fetus during pregnancy, labor, and postpartum through breastfeeding. Appropriate management can reduce the consequences of HIV in pregnancy, ideally starting with preconception counseling and planning pregnancies when the viral load is at a minimum. During pregnancy, appropriate combined antiretroviral (cART) medication is essential, along with close monitoring of the viral load. Careful planning for delivery is necessary, especially for women whose viral load is unknown or not controlled at the time of delivery to limit vertical transmission.