HIV (Human Immunodeficiency Virus)

Please take note: The chapter on HIV/AIDS is an overview! Complete and detailed information may be found in the many sites/links listed at the end of this section. This chapter is a good primer. For those seeking advanced knowledge – consult the approved links below.

What is HIV/AIDS?

AIDS, or acquired immunodeficiency syndrome, is a disease caused by a virus (HIV) that attacks and weakens the immune system (the body’s defense mechanism). Scientists have designated the virus as HIV or human immunodeficiency virus.

Is HIV/AIDS a common infection?

The HIV/AIDS epidemic is one of the greatest killers in the history of humanity: having killed more than 20 million individuals across the globe. There are a further 40 million individuals living with this disease at the moment according to UN AIDS. In Quebec, the disease is in constant progression. It is estimated that approximately 15,000 people are infected with HIV in Quebec and that another 4,500 have died as a result of their infection.

What are the symptoms of HIV/AIDS ?

In the weeks subsequent to the entry of HIV into the body, approximately 30 % of infected individuals will experience symtpoms similar to the flu (influenza) or mononucleosis (fever, headaches, sore throat, skin rash, fatigue, muscular aches and pains, etc.). It is at this stage of the infection that the infected individual is said to be in "PRIMO-INFECTION" or first stage. These symptoms resolve spontaneously with time and the infection then progresses into its second stage. All infected individuals (even those who do not suffer initial symptoms) will develop antibodies against the HIV virus. The presence of detectable antibodies occurs between three weeks and three months. A reliable time frame when considering a screening test for HIV is "3 months elapsed since the last sexual relations that concern you with respect to HIV". Once three months has elapsed and your test results are negative – the result is almost 100% reliable. When positive, this is the state termed as seropositive for HIV.

The virus can live in the body for several years (5-7 years on average, with a great deal of individual variability) without manifesting its presence – this may be termed a latent phase. During this latent phase, there are two more stages; asymptomatic stage 2 (HIV-positive with no HIV related symptoms or problems) and symptomatic stage 3 (HIV-positive with one or more HIV related symptoms. Most patients in stage 2 asymptomatic infection feel well and have no physical complaints pertaining to virus.

The infection passes into the fourth stage when the patient begins to suffer symptoms related to viral progression. Symptoms may include fever, nocturnal sweats, weight loss, swollen and/or sensitive lymph nodes, chronic diarrhea, skin rashes, etc.) Eventually, when the immune system has been severely compromised or damaged, the infection enters into its fourth phase which is AIDS (Pneumocystis Carinii pneumonia, the invasion of the digestive system by mushrooms/yeast, Kaposi’s sarcoma [blue or browm cutaneous cancerous nodules], lymphoma [lymph node cancer], neurological manifestations, etc.)

How is the HIV/AIDS virus transmitted?

The methods of transmission of HIV in the human are now well understood:

No risk:

• Kissing without the exchange of saliva
• Mutual masturbation without using vaginal secretions or sperm as lubricant.
• Massage and body contact, without exchange of body fluids.

Very low risk:

• Kissing with saliva exchange (deep or french-kissing)
• Oro-genital sexual relations (fellatio or cunnilingus) without ejaculation or swallowing sperm or vaginal secretions.

Low risk:

• Oro-genital sexual relations (fellatio or cunnilingus) with ejaculation and/or ingestion of sperm or vaginal secretions (including menstrual flow).
• Protected (with condom) vaginal or anal penetration.

Very high risk:

• Unprotected (without condom) penile penetration into the vagina or anus.
• The sharing of sexual toys or objects contaminated with sperm, blood or vaginal secretions.
• Sharing needles, syringes, or other drug paraphernalia used in the preparation or injection of illicit drugs.
• The birth of an infant to a seropositive mother not treated for her HIV/AIDS.
• Blood products, blood, organs or sperm received during the period of 1979 and November 1985 (dates during which no HIV detection test was available) are deemed to be potentially at risk for having transmitted HIV.

It is important to note that we cannot contract HIV by shaking hands, swimming in public pools, sitting on public toilets, from clothing, food utensils, glasses, plates, food, telephones, mosquitoes or animals. There is no risk of contracting the infection in a bus, train or elevator occupied by an individual infected with HIV or AIDS.

HIV/AIDS and pregnancy

Several studies have demonstrated the fact that it is possible for the HIV virus to be transmitted from the untreated infected mother to her newborn during delivery. The risk of infection from mother to child is infrequent prior to delivery, indicating that infection of the newborn likely is associated with the trauma and blood contact that may occur during spontaneous vaginal delivery. Research into treatment of infected expecting mothers has allowed for great progress in the prevention of such transmission (see below).

HIV/AIDS in the newborn

20 to 30 % of newborns born to infected untreated mother will be infected with the HIV virus. It is therefore extremely important to undertake a screening test early in pregnancy so as to detect HIV early and thereby take measures to prevent infection of the fetus/newborn. Ideally, medications should be started in the second trimester and continued until at least one month post-partum (after the delivery) – or longer, as indicated. With an early treatment intervention and adequate prenatal/postnatal follow-up, it is possible to avoid maternal to fetal transmission in almost 100 % of cases. Again, HIV status needs to be known, and access to medications is key (not the case in much of the developing world).

How is HIV/AIDS diagnosed?

The only way to definitively confirm the presence of an infection by HIV is to undertake a confirmatory blood test. Patients with classical symptoms and a high-risk profile may be suspected of having HIV/AIDS, yet still require confirmation via two separate HIV blood tests. When an individual is suspected of being in the throes of "primo-infection" your physician may request special cofirmatory blood tests (standard tests may take time to become positive).

Is there a treatment for HIV/AIDS ?

In industrialized countries such as ours, HIV is no longer the great devastator that it was in its first 15 years of havoc. For the majority of individuals infected with HIV, the infection and progression towards AIDS has become a chronic illness that requires longterm careful clinical follow-up, similar in many ways to other chronic illnesses such as diabetes, hypertension, atherosclerosis, etc. This statement is not meant in any way to banalize an infection by HIV/AIDS – living with HIV and its associated treatment regimens is in no way easy. The analogy with other chronic illnesses is an attempt to suggest that with proper care, disciplined treatment and a great deal of motivation most individuals can expect a to live long and live well.

In 1996, important and fundamental research into the biology of HIV succeeded in initiating the development of extremely potent medications that were and are able to impede or block the replication of the HIV virus. Unfortunately these medications are still unable to kill the virus. It is thanks to combinations of several of these medications (typically three medications) or triple therapy that reconstitution of the immune system is possible. In order for these medications to be successful in their ability to permit the immune system to rebuild itself, and this over the long-haul, they must be taken with great discipline. Since the advent of these "highly active antiretroviral therapies" we have observed an 80 % decrease in HIV/AIDS related mortality rates!

Your physician can help you to determine the optimal treatment for you.

Who is at risk of contracting HIV/AIDS?

While infection rates in the population of men having sex with men (MSM) are well known, the infection rates in other risk populations has evolved over the last several years. In MSM, infection rates originally levelled off with prevention and education campaigns, the last couple of years have indicated a new rise in HIV infections in young MSM (reflecting a return to unsafe sexual practices). Infection rates in intravenous drug users (IDU) continues to rise as a result of shared injection paraphernalia (this population is for the most part also coinfedted with hepatitis C or hepatitis B virus – see chapter on hepatitis). A rise in the number of women infected by HIV has been noted over the last couple of years (likely reflecting infection via IDU or sexual relations with infected IDU partners…this does not explain all new cases).

How can HIV/AIDS infected individuals decrease the chance of transmitting their virus ?

• Use condoms for all sexual relations (oral sex, vaginal and/or anal penetration).
• Avoid sharing needles or injectable drug associated paraphernalia.
• Avoid sharing your toothbrush, razors, nail file or any other personal article that may be contaminated with traces of blood.
• Cover all wounds, cuts and open sores with a bandage or dressing.
• Clean all surfaces that may be contaminated with your blood. Use a mixture of one part bleach to nine parts water as an effective disinfectant.
• Do not give blood
• If you are pregnant, you can greatly reduce the risk of transmitting HIV to your unborn baby with the use of anti-HIV medications. Ideally these should be started by the beginning of the second trimester.

How can I prevent infection by HIV/AIDS?

• Ensure that all your sexual relations are protected or "safe".
• Avoid sharing needles, syringes or other drug-related paraphernalia.
• Avoid sharing your toothbrush, razor, nail file or other personal instrument that may be contaminated by blood.
• Wear gloves if you are at risk of body fluid contact and work in an environment where care to HIV-infected individuals is present.

If you are accidentally exposed to HIV:

• adequately wash the skin with soap and water (scrubbing is not necessary);
• adequately rinse your mouth or eyes in the event of exposure;
• consult a health care professional, familiar with the approach and management of accidental HIV exposures. It is important to evaluate the need for preventive or prophylactic HIV medications;
• disinfect all blood-contaminated surfaces with Dakin’s solution (one part bleach to nine parts water).

Post-exposure prophylaxis (PEP) in the event of a high-risk sexual contact…what to do?

Over the past several years, research into the field of prophylaxis for high-risk sexual contacts has been/ and is still under investigation. For example, in those couples where one partner is infected (and the other is not – called a sero-discordant couple), if there is a sexual accident; the condom breaks, the condom remains in the vagina or rectum, unprotected penetration occurs for other reasons (drug or alcohol related) – a preventive treatment may be envisaged. It is important to stress that this is not the "morning-after pill". Far from it!! This is an area of research wherein it is difficult to assess the efficacy of such preventive treatments. The theory is based on and extrapolated from preventive approaches used with success in occupational and maternal-fetal transmission cases (needlestick and delivery risks). Such treatment plans suggest a potential benefit…there is no guarantee!! Prevention remains your best protection against the transmission of HIV/AIDS.

If you have been exposed/potentially exposed to HIV..What to do?

• Consult a physician familiar with PEP protocols
• Remember that timing is critical when considering the use of PEP treatment – ideally the sooner you consult, the better. The sooner medications are started, the better. Most clinicians are in agreement that when greater than 72 hours has elapsed since sexual contact – the benefits of a prophylactic treatment are likely lost. The best scenario is when consultation occurs immediately after the accident/event or within 24 hours.
• Your physician will evaluate your level of risk, your ability to take and tolerate medications and when appropriate will recommend a triple-therapy. The decision to ultimately take medications remains your own. Your physician will assist you in arriving at the best situation for you.
• Treatment is for 4 weeks. Again, this is definitely not the morning-after pill.
• Strict follow-up is important during and after the treatment, so as to ensure that side-effects to medications remain manageable. Follow-up and blood tests during the treatment period are critical in the prevention of serious medication related side effects.
• An HIV test will be done on the day of consultation, at 1 month and at 3 months time. This so as to confirm your HIV status at the beginning, during treatment and once the test eclipse period has passed.
• Ideally, the more you know about your partner (medication history, laboratory results, successes or failures with respect to treatment) – the better in tailoring the PEP treatment for success in the prevention of infection by HIV.

What does the future hold?

Presently, there are approximately 20 new anti-HIV medications in development and research. These drugs will likely become available over the next several years. Many of these novel medications will offer several advantages over existing medications: simplified dosing schedules, reduced risk of medication toxicity/side effects and a better resistance profile (less chance that the virus will overcome the medication). There are several medications under study that will attempt to attack the HIV virus and its ability to survive via mechanisms different from available treatments. Other points of interest include research into attacking the virus in the body’s reservoirs (regions where the virus is protected from medications), mechanisms to reinforce the body’s own immune response against HIV and improving the cell’s defenses against HIV infection.

When can we expect a vaccine against HIV/AIDS?

Unfortunately, it will be many years of research before an effective and safe vaccination against HIV is available. This is in part due to the virus’ ability to mutate and adapt. Despite this news, the enormous progress that has been realized over the past years with regards to the successful treatment of HIV portends a great deal of optimism. A great deal of time, money and ressources are continually dedicated to the research into an effective vaccine. It is always possible that an important breakthrough is on the horizon, similar to that seen in 1997 when the arrival of powerful new medications transformed HIV from a fatal infection into a chronic illness!